In Health Care, Republicans Could Learn From Rwanda

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It is not perfect. A comparative study of health reform in developing countries found that fewer than 60 percent of births there were attended by skilled health workers. Still, access to health care has improved substantially even as the financial burden it imposes on ordinary Rwandans has declined. On average, Rwandans see a doctor almost twice a year, compared with once every four years in 1999.

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A mother looking after her son in a hospital south of Kigali. Rwandans now see a doctor almost twice a year on average, up from once every four years in 1999.

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James Akena/Reuters

Rwandan lives may be short, but they are 18 years longer than they were at the turn of the century — double the average increase of their peers in sub-Saharan Africa.

More than 97 percent of Rwandan infants are vaccinated against diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae Type B, polio, measles, rubella, pneumococcus and rotavirus, noted a 2014 study led by Dr. Paul Farmer, of Harvard Medical School, and Dr. Agnes Binagwaho, then Rwanda’s health minister.

Almost all Rwandan adolescent girls are vaccinated against human papillomavirus, which causes cervical cancer. That compares with about four in 10 girls in the United States.

Republicans, I know Rwanda — with its poverty, illiteracy and autocratic government — is not in the same peer group as the United States. But in some dimensions of health care, it gives the United States a run for its money.

Its infant mortality rate, for one, dropped by almost three-quarters since 2000, to 31 per 1,000 births in 2015, vastly outpacing the decline in its region. In the United States, by contrast, infant mortality declined by about one-fifth over the period, to 5.6 per 1,000 births. In Portugal — a developed country that is not quite as rich — it fell by almost half, to 3.

Critically, Rwanda may impress upon you an idea that has captured the imagination of policy makers in even the poorest corners of the world: Access to health care might be thought of as a human right. The idea is inspiring countries from Ghana to Thailand and from Mexico to China to develop, within their political and financial limitations, universal health care systems to offer some measure of access to all.

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How Senate Republicans Plan to Dismantle Obamacare

A comparison of the Senate health care with the Affordable Care Act.

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As you keep looking for ways to take away the health insurance of tens of millions of Americans of limited means, the experience of these countries might help you consider alternative approaches to improve the American health care system while still providing access for all.

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Since Ghana began its health care reform in 2003, access has increased from 6.6 percent to 38 percent of the population, according to an analysis by researchers at the World Bank. In Peru, coverage has increased from about 37 to 62 percent since the start of reforms; in Vietnam, from 16 to 67.5 percent; in Thailand, from 63 to 96 percent.

Every country has followed its own path and run into its own walls. Yet collectively, these nations offer a few basic lessons that might help you understand how health care in the United States could be improved.

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One is that it is hard to finance a universal system with voluntary payments. The young and the healthy will be reluctant to pay, leaving only the sick in the insurance pool, which would push the cost of premiums to unaffordable heights and ultimately cause the system to collapse. “No country has attained universal population coverage based on a system organized around voluntary prepayment,” the World Bank researchers wrote.

In fact, they said, in 2012 there were only five countries with more than 600,000 people where voluntary payments accounted for more than one-fifth of total health spending. (The United States was one.) Several developing countries that initially leaned on voluntary premiums to finance their push toward universal health care have turned increasingly to direct government funding, either from earmarked taxes or general budget revenues.

Another rule of thumb is that it is best to consolidate the health care system into one big risk pool for the entire population, as Ghana, the Philippines, Indonesia and Vietnam are aiming to do.

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A doctor examining tuberculosis patients at the National Lung Hospital in Hanoi, Vietnam. The country is aiming to consolidate its health care system into one risk pool for the entire population.

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Justin Mott for The New York Times

Having several different pools — one for the poor, another for the aged, another for employees of this or that company — blocks the cross-subsidization from the rich to the poor, the young to the old and the healthy to the sick upon which insurance relies. It makes it tougher to control costs, as doctors and hospitals facing a cost-control squeeze in one pool might simply charge more to patients or insurers in the other.

A critical third point is that it will be prohibitively expensive to provide universal health care access without cost controls and mechanisms to pare back unnecessary care. Rwanda, for instance, introduced a results-based financing approach that pays providers based on performance.

Thailand’s National Health Security Office, the single purchaser for three-quarters of the country’s population, has negotiated lower prices of medicines, medical products and interventions. To offer universal access to renal replacement therapy without breaking the budget, it limited access to more expensive hemodialysis therapy — paying instead for cheaper peritoneal dialysis.

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By the way, Republicans, the architects of Obamacare knew about these things. The workarounds and fixes that make it look a bit like a Rube Goldberg device were designed to address these challenges within the limitations of a political system that had tried — and failed — to create universal health insurance many times before.

Try proposing the use of effectiveness metrics to pare back the 17 percent of the nation’s gross domestic product sucked into the maw of the health care industry. You won’t have to wait long to hear about “death panels.” Want to propose a single-payer health care system financed with higher taxes, maybe one that pays doctors a wage instead of a fee for service? It probably won’t take long for the American Medical Association to call you a communist.

But Republicans, the imperfections of the Affordable Care Act in dealing with an unwieldy, expensive health care system do not add up to a reason to throw its achievements away. Prosperity lies in the opposite direction. Just take a look around the world.

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