Universal Health Insurance: Born with the best of intentions but now facing a mid-life crisis

Christopher Hughes

HK Pract 2024;46:68-72

Good afternoon, everyone.

Firstly, can I take this opportunity to acknowledge:

Dr. David Chao, President of the Hong Kong College of Family Physicians, and all his colleagues from the College here today.

I wish to recognise the fine efforts of the Hong Kong College Staff in making our travel and stay here in Hong Kong so seamless.

Dr. Nicole Higgins, President of the Royal Australian College of General Practitioners.

Presidents and Senior Representatives of Specialist Colleges from Hong Kong.

Distinguished Guests

Our new Graduates

Ladies and Gentlemen

Boys and Girls.

At the outset can I wholeheartedly congratulate all the new Graduates on their tremendous achievements in preparing to serve their communities as Specialist Family Physicians.

You have the best wishes from the RACGP as you begin your careers in Family Medicine.

Can I take this opportunity to remind you that the future of General Practice is in your hands!

And there is absolutely no pressure!

I would like to make special mention of those who have supported you in your journey to this point:

In particular I would like to commend the efforts of your families and friends together with your teachers and mentors so well supported by the Hong Kong College of Family Physicians.

I would like to sincerely thank the Hong Kong College of Family Physicians for inviting me to deliver the 34^th Dr. Sun Yat-sen Oration.

I first came to Hong Kong in 1983 as a young Australian traveller in the first leg of his Grand Tour.

Staying at the old YMCA, I had to borrow clothes from a friend to go to dinner at the Mandarin Hotel!

Who would have thought that my professional journey would lead me to stand before Hong Kong’s finest 41 years later.

I am deeply honoured.

My talk is entitled:

Universal Health Insurance, born with the best of intentions but now facing a midlife crisis.

In this oration I will attempt to outline the global origins of Universal Health Insurance, identify the current challenges and offer solutions for a better future for universal healthcare.

I will particularly focus on the issues facing General Practice.

Dr. Sun Yat-sen is one of very few leaders in history who is revered across the political spectrum. He has strong early connections to Hong Kong, so it is entirely fitting that his name is linked to the oration within this ceremony.

He arrived here at the end of the 19^th Century. At that time Hong Kong was a real melting pot of ideas and cultures. It proved to be a pivotal finishing school for someone who had an enormous impact on the history of Modern China.

He developed a political manifesto for a new China based on 3 Principles.

The first principle was Nationalism whose objective was to foster a sense of national unity and independence from foreign domination.

The second principle was Democracy where the Government was to be elected for and by the people.

The third principle he called the People’s Livelihood.

This principle promoted land reform and ensured that all citizens had the right to access the basic necessities of life including food, shelter, and employment.

With some artistic license I would like to add Universal Healthcare as a basic right supporting the principle of People’s Livelihood.

As a Hong Kong Medical Graduate, I am sure that Dr. Sun Yat-sen would not mind.

Healthcare prior to the 19^th Century was a far cry from the evidenced based care we all now enjoy.

High infant mortality and low life expectancy across the world were the norm.

Better understanding of the factors that impacted on public health, with particular regard to infectious disease, led to a reduction in premature deaths. Advancements in the science and practice of Medicine offered new hope for better and longer lives.

Universal health insurance, the idea that all citizens should have access to healthcare services regardless of their financial means, has a rich and varied history that can be traced back to the 19^th Century in Europe.

One of the pioneers was Germany, where Chancellor Bismarck introduced the Health Insurance Acts of 1883. This legislation marked the first major step towards universal health coverage.

Bismarck’s motivation was not purely altruistic. His purpose in establishing a system with funded universal healthcare was to appease the working class and to oppose the rising tide of Socialism.

The so called Bismark model mandated that employers and employees contribute to a health insurance fund, providing coverage for workers in case of sickness.

In the United Kingdom (UK), the National Insurance Act of 1911 established health and unemployment insurance for the British Working Class. The system relied heavily on approved providers which included trade unions and friendly societies.

The Beveridge Report of 1942, authored by British economist William Beveridge, laid the groundwork for the modern welfare state in the UK.

Beveridge envisioned a comprehensive system of social insurance, covering healthcare, unemployment benefits and pensions.

This vision was championed by the then British Socialist Labour Government with the establishment of the Beveridge Model of Universal Healthcare manifesting as the National Health Service in 1948.

In the second half of the 20^th Century many countries set about reforming their healthcare systems.

Japan implemented a universal health insurance system in 1961.

The Japanese model required all citizens to join either employer-based or community-based health insurance schemes, ensuring nationwide coverage. This system reflected the desire to rebuild a cohesive society after a period of enormous upheaval.

Canada established its Medicare system in stages, starting within the Province of Saskatchewan in 1947 and culminating in the nationwide Medical Care Act of 1966.

Canadian Medicare, characterised by public funding and private delivery, provided universal coverage for hospital services and General Practice.

The United States (U.S.) presents a unique case in the history of universal health insurance. Unlike many other developed countries, the U.S. has not adopted a comprehensive universal healthcare system. Instead, it relies on a complex mix of private and public insurance schemes.

The establishment of Medicare and Medicaid in 1965 marked significant steps towards expanding healthcare coverage, primarily for the elderly and lowincome individuals. However, a substantial portion of the population remained uninsured.

The Affordable Care Act (ACA) of 2010 or the ACA, better known internationally as Obamacare, sought to address this gap by expanding Medicaid eligibility and establishing health insurance marketplaces.

The ACA aimed to increase coverage and reduce healthcare costs, but it faced political opposition and legal challenges reflecting broader ideological divides regarding the role of government in providing social services.

The delivery of universal health insurance in Australia had a long and complex gestation.

In 1946 the Australian Constitution was amended to allow the Federal Government to provide medical and dental services which laid the groundwork for future health funding reforms.

Medibank was introduced by the Whitlam Government in 1975 as Australia's first universal health insurance scheme, aimed at providing free hospital care and subsidised medical care for all Australians.

The RACGP advocated for the importance of embedding GPs at the primary care foundation of the new healthcare framework.

Despite broad support, Medibank faced resistance from various quarters, including the Australian Medical Association, who were concerned about government control over healthcare.

In 1984, the Labor Government replaced Medibank with Medicare, re-designing a universal health insurance scheme with mandatory contributions through the Medicare levy, initially set at 1.5% of income and later increased to 2% to fund the National Disability Insurance Scheme which was established in 2013.

The RACGP supported this transition, recognising that Medicare addressed some of the limitations of Medibank and provided more stable and comprehensive health coverage.

It ensured that GPs were appropriately renumerated and supported for their pivotal role in Australian Healthcare.

The RACGP more recently successfully lobbied for the inclusion of preventive care, chronic disease management, mental health care and other essential services in the Medicare Medical Benefits Schedule.

In the early phases of the COVID-19 pandemic the RACGP’s efforts were realised with the expansion of telehealth services under Medicare to ensure that patients could access care remotely.

The widespread adoption of Universal Health Insurance seemed to promise so much to support a healthy future for disadvantaged patients everywhere, so what could possibly go wrong?

Universal Health Insurance systems around the world are now grappling with a multitude of challenges that threaten their ability to effectively protect and promote the health of populations.

These challenges are complex, reflecting changes in disease patterns, demographic shifts, technological advancements, environmental factors, and socio-political factors.

The COVID-19 pandemic has highlighted the vulnerability of global health systems to manage emerging infectious diseases. The rapid spread of this virus overwhelmed many healthcare systems, exposing gaps in preparedness and response mechanisms.

Key issues included poor policy preparedness, inadequate surveillance systems, insufficient stockpiles of essential medical supplies, and a lack of framework for international cooperation.

Despite the best attempts by Public Health leaders, many denied the significance of the pandemic and disputed the attempts by Governments to reduce the impact of what has been the most deadly infectious disease in living memory.

I think we would all agree that the COVID-19 Pandemic has been a lesson well learnt.

Chronic disease such as Ischaemic Heart Disease, Diabetes, and Cancer are leading causes of mortality. Global public health systems are struggling to address the resource and economic growing burden of chronic disease in aging populations.

Socioeconomic disparities invariably lead to unequal access to healthcare services particularly in developing countries. This inevitably results in worse health outcomes for those who are poor.

Education and health literacy play a crucial role in determining access to quality healthcare.

This was a big issue within my own practice.

I worked in an area that had a 50% functional literacy rate. This, despite our best efforts, had significant consequences in that community’s health outcomes.

Back in 2010 I participated in a process of pandemic planning with the Tasmanian Health Department.

In those days there was a real ignorance within the Department of the impact of poor health literacy and the need to factor this in developing mass communication strategies.

Fortunately, they now have much better strategies to account for all levels of literacy.

Many health systems are facing significant workforce burnout, driven by high patient loads, long working hours, and the emotional toll of dealing with the pandemic.

General Practice in the UK, Canada and Australia is at a real crisis point.

This has been a consequence of poor GP recruitment strategies, chronic underfunding and increased administration burden in the face of a more complex and older patient base.

In Canada, it is predicted that within 5 years, one in four people will not have access to a GP.

In Australia, only 10 % of Medical Graduates see their future in General Practice.

The global GP workforce is getting older.

In Australia, the average age of a GP is 53.

The best health advice to older adults in Australia is to quickly get a good young GP, and you will get a lifetime of the quality care before your very tired GP needs to retire!

Mental Health disorders are a growing concern worldwide, this has been quite evident since the start of the COVID Pandemic, and yet they often receive insufficient attention and resources within the public health systems.

The stigma surrounding mental health, coupled with a lack of specialized services and professionals, hampers effective treatment and support.

Environmental factors, including pollution and climate change, have already had a significant impact on public health. Air and water pollution contribute to respiratory and cardiovascular diseases, while climate change increases the frequency and severity of extreme weather events, affecting food security and fragmenting health services.

To use Australia as an example, recent fires and floods had an enormous impact on the abilities of GPs in remote areas to deliver both regular care to patients and to manage the enormous health burden that inevitably follow these so called natural disasters.

Dr. Michael Mosely, the widely acclaimed BBC presenter, left us just a few short weeks ago.

He fondly remembered his time here as a child in Hong Kong where his Father worked as a Banker.

He tragically died walking on a day when the temperature on the idyllic Greek Island of Symi was 12 degrees Celsius above the long-term average for early June.

At least 7 other tourists died in the 2 weeks following Michael Mosley’s death as a consequence of the heat wave that Greece experienced in early June this year.

It is not hard to imagine the health threat that is posed by Global Warming.

While technological advancements offer tremendous potential to enhance healthcare delivery, they also pose challenges particularly in relation to information security. The integration of digital health tools, such as telemedicine, electronic health records, and AI-driven diagnostics, all increase the risk of cyber-crime.

I am sure that those who work in the tertiary education sector have been quite busy addressing the risks posed by AI, particularly as it applies to assessment.

Funding is still, all too often, spent on facilities and technologies to support those at the end of their lives who were not given the opportunity in their early years to live with a better emphasis on good nutrition, exercise and preventative health because of inadequately funded Public Health promotion.

A very wise Chinese Philosopher Lao Tzu said it well 2,500 years ago.

‘If you don’t change direction, you may end up where you are heading.’

Effective public health systems are vital for ensuring the well-being of populations, and overcoming these challenges is essential for achieving global health security and equity.

Addressing the crisis in universal health insurance requires recognition by all Governments that current approaches are not fit for purpose in a world that is undergoing significant change.

Multifaceted approaches that consider policy reform, financial strategies , healthcare system improvements will be needed to regain the promise of better health for all in the future.

Stakeholders, including patients, healthcare providers, and policymakers, need to be engaged at every level in policy development and implementation.

The RACGP has, in recent years, increased its political lobbying efforts at both a State and National Level. Whilst we have had some real successes we regularly come up against Politicians paying more attention to their political donors rather than being influenced by the evidence based approach of the College.

Effecting change is often frustrating and never easy.

Taxation and levies linked to health care must be indexed to reflect the increasing cost and complexity of all levels of healthcare.

Administration processes need to be simplified to reduce overhead costs and improve the overall efficiency of the healthcare system whilst identifying and prosecuting fraud when appropriate.

In recent years the lifesaving advances in HIV and Hep C treatment have once again identified the profit motivation of many Multinational Pharmaceutical Companies.

More effort needs to be made to control the cost of medications by supporting government funded pharmaceutical research removing the costly private research excuses behind price gouging.

Governments also need to ensure that the cost of medications needs to reflect the actual costs of development and production.

Quality care needs to be supported by ongoing recruiting and training for healthcare professionals. There needs to be a much greater emphasis on teaching the benefits of lifestyle choices in our interactions with patients.

There needs to be a better appreciation of the need for research in General Practice to support both recruiting and outcomes in Primary Care.

The social determinants of health needs to be recognised and addressed by Governments. Better housing, education, and employment opportunities will invariably improve overall health outcomes.

Investing in preventive care and public health initiatives will reduce the burden of chronic disease and lower the overall healthcare costs. This includes better support for vaccination programs, health education, regular screening, and healthy exercise through recreation.

Tobacco use and high sugar and salt intake need to be relegated to history.

Better management of the stressors that leads to mental illness and integration of mental health services into primary healthcare and expanding communitybased services will be crucial in addressing the current surge in mental health illness.

Better investment in health information technology will lead to an improved and more secure sharing of data, better patient records, and more efficient care coordination.

We need to utilise Artificial Intelligence and data analytics to an research health trends, personalise treatments, and identify cost-saving opportunities within the healthcare system.

Some of you here will remember Dr. Bastian Seidel, a former RACGP President Bastian works in an isolated rural area and is currently trialling the use of AI to interpretate the findings of GP performed Cardiac Ultrasound. This study hopes to establish the value and accuracy of using AI to make early diagnoses of cardiac disorders and to individualise treatment plans all within a rural GP setting.

It seems that with AI the sky is the only limit!

In conclusion:

There is a wonderful old saying.

An apple a day keeps the doctor away.

The saying comes from Wales in the mid-19^th Century.

Whilst I love apples, there is little doubt that the solutions to the emerging global crisis in Universal Health Care will be much more complex than regular consumption of fruit!

For my part I can only hope that a well recruited and trained, responsive and valued General Practice Profession will play a significant part in this brave new world.

And I am sure Dr. Sun Yat-sen would approve.

Many thanks for listening.