What the US Could Learn from Thailand about Health Care Coverage

Newborn babies in a Bangkok hospital on Dec. 28, 2017.They are wearing dog costumes to observe the New Year of the dog.  Athit Perawongmetha/Reuters

Newborn babies in a Bangkok hospital on Dec. 28, 2017.They are wearing dog costumes to observe the New Year of the dog. Athit Perawongmetha/Reuters

The open enrollment period for the Affordable Care Act (ACA) draws to a close on Dec. 15. Yet, recent assaults on the ACA by the Trump administration stand in marked contrast to efforts to expand access to health care and medicine in the rest of the world. In fact, on Dec. 12, the world observed Universal Coverage Day, a day celebrated by the United Nations to commemorate passage of a momentous, unanimous U.N. General Assembly resolution in support of universal health coverage in 2012.

While the U.N. measure was nonbinding and did not commit U.N. member states to adopt universal health care, many global health experts viewed it as an achievement of extraordinary symbolic importance, as it drew attention to the importance of providing access to quality health care services, medicines and financial protection for all.

Co-sponsored by 90 member states, the declaration shined a light on the profound effect that expansion of health care coverage has had on the lives of ordinary people in parts of the world with far fewer resources than the U.S., including Thailand, Mexico and Ghana. Can the U.S. learn anything from these countries’ efforts?

US and Thailand: A study in contrasts

I came to understand these changes as I researched and wrote my book, “Achieving Access: Professional Movements and the Politics of Health Universalism.” The book offers a comparative and historical take on the politics of universal health care and AIDS treatment, featuring Thailand as the primary case. For me, Thailand’s remarkable achievements also put into perspective some of the work we still have to do here in the United States with respect to health reform.

Before the reform, Thailand had four different state health insurance schemes, which collectively covered about 70 percent of the population. The reform in 2002 consolidated two of those programs and extended coverage to everyone who did not already receive coverage through the country’s health insurance programs for civil servants and formal sector workers.

Thailand’s universal coverage policy contributed to rising life expectancy, decreased mortality among infants and children, and a leveling of the historical health disparities between rich and poor regions of the country. The number of people being impoverished by health care payments also declined dramatically, particularly among the poor.

However, Thailand’s reform had other important consequences that aimed to make the reform sustainable as well. Sensible financing and gatekeeping arrangements – that tied patients to a medical home near where they lived and provided fixed annual payments for physicians to cover outpatient care – were instituted to curb the kind of cost escalation that has historically been a hallmark of the United States (though it has slowed lately). The reform also improved the quality of care for patients in remote areas by mandating that qualified providers in community hospitals collaborate more extensively with rural health centers.

A computer screen promoting this year’s open enrollment, which will run 45 days. In years past, open enrollment continued for months.  Ricky Kresslein/Shutterstock.com

A computer screen promoting this year’s open enrollment, which will run 45 days. In years past, open enrollment continued for months. Ricky Kresslein/Shutterstock.com

The United States, by contrast, seems to be moving in the opposite direction, both in terms of insurance coverage and health outcomes. Although recent Republican efforts to repeal the Affordable Care Act were narrowly defeated, lawsuits that aim to terminate popular pre-existing conditions protections continue. In addition, the Trump administration has sought to weaken the reform in other ways: including by cutting the open enrollment periods, which ends Dec. 15 and lasts 45 days; cutting outreach and advertising for open enrollment; and threatening to suspend risk adjustment payments to private insurers, which help to stabilize the market.

Moreover, effective repeal of the Affordable Care Act’s individual mandate through a provision in the 2017 Tax Reconciliation Act that reduces the penalty for not having insurance to zero in 2019 will have the effect of reducing the number of insured. This will have an effect on health insurance markets, likely reducing the number of younger and healthier people that help give balance to health insurance risk pools and that help keep overall costs down. And without the financial protection afforded by health insurance, those who are uninsured may face rising rates of medical bankruptcy, to say nothing for the loss of access to sorely needed medical care.

Learning from Thailand

To be sure, the Thai and American contexts are very, very different. While health spending stands at around 4 percent of GDP in Thailand, in America nearly 20 percent, or one-fifth, of the country’s total economic output is spent on health. Yet, in some ways, that makes Thailand’s achievement all the more remarkable. And while no program is perfect, Thailand’s reform is one of the reasons that health costs in Thailand have remained so low, despite such a dramatic increase in coverage.

The use of generic drugs in Thailand is a strategy to keep costs low.  Room's Studio/Shutterstock.com

The use of generic drugs in Thailand is a strategy to keep costs low. Room's Studio/Shutterstock.com

Reformers also drew on other innovative policy instruments to keep costs down, including the Government Pharmaceutical Organization that produces generic medication for the universal coverage program and the use of compulsory licenses, which allow governments to produce or import generic versions of patented medication under WTO law.

The Affordable Care Act similarly sought to improve access, while curbing costs. Some of the most important mechanisms to curb costs fell victim to the legislative process however. Most notably, lobbyists succeeded in killing the “public option,” a government (as opposed to private) health insurer with much lower administrative costs that aimed to bring costs down among private health insurers through competition with them.

Although the reform in Thailand was popular among the masses, it also saw its share of detractors. Medical associations that represented doctors who saw the policy as a threat came out against it. Likewise, beneficiaries of the existing programs for civil servants and employees of large, tax-paying businesses feared that their own benefits would be diluted by a new single payer program. Despite progress expanding access to everyone, the new program introduced in 2002 still sits alongside separate programs for civil servants and employees of large, tax-paying businesses.

What the contrast makes clear, however, is that reforms done properly can expand access while at the same time instituting measures that help to contain costs. The U.S., in my view, should pursue similarly creative and constructive reforms that seek to do both.

What does that look like in the United States? To me, that means preserving the ACA’s individual mandate and protections related to pre-existing conditions; creating (or expanding) a public insurer like Medicare to compete alongside private insurers and keep costs down; addressing the lack of price transparency in our nation’s hospitals; and actively negotiating with pharmaceutical companies and hospitals to bring costs of drugs and health care down for millions.

Done sensibly, developing nations like Thailand are proving that they do not have to join the ranks of the world’s wealthiest nations for their citizens to enjoy access to health care and medicine. Using evidence-based decision-making, even expensive benefits, like dialysis, heart surgery and chemotherapy, need not remain out of reach. Policymakers in all countries can institute reforms using tools that promote cost savings at the same time they improve access and equity.

While efforts to implement universal coverage are not without challenges, these results suggest that leaders in Congress would do well to learn from countries like Thailand as they chart a fiscally responsible path forward on health care.

JOSEPH HARRIS is an Assistant Professor of Sociology at Boston University.

THIS ARTICLE WAS ORIGINALLY PUBLISHED ON THE CONVERSATION



How Women Entrepreneurs are Changing Indian Society

In India, the proportion of women in paid work is among the lowest in the world, at just over 23% – a figure which contrasts sharply with the corresponding rate of over 78% for men.

Opportunities for women to enter employment in the country are limited by a range of factors. These include a dominant tradition of female domestic responsibility, and a prevailing social patriarchy.

Deeply entrenched cultural expectations mean that women are more likely to stay at home. And when they do work, it is mainly on an informal basis, without the luxury of secured wages and contracts.

Against this backdrop, the idea of female entrepreneurship in India faces major challenges. Setting up a business can require significant efforts outside of normal work times, and can lead to women being perceived as irresponsible if they dedicate time to entrepreneurial activities.

But it seems as if things may be changing. My research on women entrepreneurs in India reveals they are contesting social, cultural and family pressures to challenge the status quo in Indian society. They are also empowering other women while providing innovative solutions to major social problems.

Some of the women I spoke to greatly inspired me with their stories. One manufacturing business founder, Pinky Maheshwari, was challenged by her son to make environmentally friendly paper. She went on to create handmade paper made out of cotton that is embedded with seeds. These can then be planted and grown into trees when the paper has served its purpose.

Her award-winning ideas have won appreciation and support from the highest levels of Indian government. She is, she told me, motivated by the idea of empowering others, and “hires women from rural and small towns so that they earn a livelihood and get acknowledged for their creativity”.

She added: “I have employed largely women and I support them in any way I can.”

A similar spirit shone through other women entrepreneurs I interviewed. Padmaja Narsipur, the founder of a digital marketing strategy firm, supports women “re-starters” to join her workforce after a break in their working lives.

She said: “Women re-starters are highly qualified and committed. I have been one myself. I have built a workplace where trust in employees, giving flexible hours, work from home options, is built into the DNA and it is paying off.”

The CEO of Anthill creations, Pooja Rai has a vision to create “interactive learning environments in public spaces with a primary focus on sustainability”, by using recycled materials to build accessible play areas in remote parts of India.

These are just some of the many Indian women entrepreneurs I met who are creating businesses of real purpose. Despite the cultural obstacles, they are changing perceptions and creating innovative businesses that have a real impact on their communities and beyond.

Their work is rewriting the rules for business, families and society while challenging the mindset that there is limited scope for them to create good businesses.

With a blend of social purpose and business acumen, Indian women are embarking on a journey to change perceptions and creating prosperity for themselves and for the nation.

This is the new face of women entrepreneurship in India. And there is evidence that public policy is increasingly supportive of this transformation while society is beginning to celebrate their successes.

Indian society is gradually becoming progressively egalitarian with much needed government initiatives such as “Beti Padhao, Beti Bachao” (Save the Daughter, Educate the Daughter) designed to improve the prospects of young girls.

Improved access to social mediaeducation, and social enterprises are all contributing to change. These are giving momentum to the aspirations of women entrepreneurs in India.

MILI SHRIVASTAVA is a Lecturer in Strategy at Bournemouth University.

THIS ARTICLE WAS ORIGINALLY PUBLISHED ON THE CONVERSATION

How Solar Energy Is Bringing Power Back to Puerto Rico

After watching Hurricane Maria devastate his native Puerto Rico, New York City-based architect Jonathan Marvel knew he needed to do anything he could to give back. He banded together a group of friends to launch Resilient Power Puerto Rico, hoping to use the strength of renewable, solar energy to provide a steady source of electricity back to the island.

Just two weeks after the ambitious initiative was born, Marvel was back in Puerto Rico installing solar panels and batteries on the rooftops of community centers. The storm had wiped out power lines and had left people without electricity. Solar-powered energy would allow them to live and operate off the grid, without reliance on fossil fuel-burning power plants. Suddenly, these solar-powered community centers were able to provide spaces where people could refrigerate medication, filter water and gather together to rely on one another in the midst of a humanitarian crisis.

At last count, Marvel and Resilient Power Puerto Rico were able to bring solar power to 20 community centers across the island—helping over 100,000 people in the process.

Still, Marvel’s work is far from over. It took nearly a year before the Puerto Rico Electric Power Authority restored power to most of the island’s residents, and, according to reports, the electricity system is in not in a much better state than it was before Maria wiped out the island.

Longer term, Marvel dreams of a day when Puerto Rico is able to shift to 100-percent renewable energy sources. He believes it is an achievable goal, and Resilient Power Puerto Rico is working to make it a reality.

“We can no longer rely on large fossil fuel burning power plants distributing energy and wires that are going to get blown down every year,” Marvel says. “We have all this power from the sun that needs to be harnessed.”

I am Congo

Get to know the Congo before you walk through the streets yourself. In this immersive experience, you'll see the vast forest of the congo, the countries colorful style, and break taking shots of life in the city. As part of the "I am" series, videographers spent time in the Congo meeting local artisans, traders and musicians. Their experience, laid out for you here.

It’s Not Just Brazil’s Amazon Rainforest That’s Ablaze – Bolivian Fires are Threatening People and Wildlife

Firefighters and volunteers have been working around the clock to tackle the flames. Ipa Ibañez, Author provided

Firefighters and volunteers have been working around the clock to tackle the flames. Ipa Ibañez, Author provided

Up to 800,000 hectares of the unique Chiquitano forest were burned to the ground in Bolivia between August 18 and August 23. That’s more forest than is usually destroyed across the country in two years. Experts say that it will take at least two centuries to repair the ecological damage done by the fires, while at least 500 species are said to be at risk from the flames.

The Chiquitano dry forest in Bolivia was the largest healthy tropical dry forest in the world. It’s now unclear whether it will retain that status. The forest is home to Indigenous peoples as well as iconic wildlife such as jaguars, giant armadillos, and tapirs. Some species in the Chiquitano are found nowhere else on Earth. Distressing photographs and videos from the area show many animals have burned to death in the recent fires.

The burnt region also encompasses farmland and towns, with thousands of people evacuated and many more affected by the smoke. Food and water are being sent to the region, while children are being kept home from school in many districts where the air pollution is double what is considered extreme. Many families are still without drinking water. While the media has focused on Brazil, Bolivians are asking the world to notice their unfolding tragedy – and to send help in combating the flames.

Dry forests of the Chiquitanos before the fires. Alfredo Romero-Muñoz, Author provided

Dry forests of the Chiquitanos before the fires. Alfredo Romero-Muñoz, Author provided

It’s thought that the fires were started deliberately to clear the land for farming, but quickly got out of control. The perpetrators aren’t known, but Bolivian President Evo Morales has justified people starting fires, saying: “If small families don’t set fires, what are they going to live on?”

The disaster comes just a month after Morales announced a new “supreme decree” aimed at increasing beef production for export. Twenty-one civil society organisations are calling for the repeal of this decree, arguing that it has helped cause the fires and violates Bolivia’s environmental laws. Government officials say that fire setting is a normal activity at this time of year and isn’t linked to the decree.

Fires burn across Santa Cruz state. Ipa Ibañez, Author provided

Fires burn across Santa Cruz state. Ipa Ibañez, Author provided

Morales has repeatedly said that international help isn’t needed, despite having sent just three helicopters to tackle the raging fires. He argued that the fires are dying out in some areas – although they continue to burn in others and have now reached Bolivia’s largest city, Santa Cruz de la Sierra. Many say that the fires could have been contained far sooner with international help, as videos show volunteers trying to beat back the fires with branches.

As the fires worsened, people gathered to protest in Santa Cruz state. Chanting “we want your help”, they complained that the smoke was so bad they were struggling to breathe. They want Morales to request international aid to fight the fires. While firefighters and volunteers struggle to tackle the blaze in 55℃ heat, Bolivians have set up a fundraiser to tackle the fires themselves.

The extreme heat has made fighting the fires intolerable for those involved. Ipa Ibañez, Author provided

The extreme heat has made fighting the fires intolerable for those involved. Ipa Ibañez, Author provided

A fortnight after the fires began, a supertanker aeroplane of water arrived, hired from the US. But if the reactions to the president’s announcement on Twitter are anything to go by, many Bolivians think this is too little, too late. Morales is fighting a general election and has faced criticism for staying on the campaign trail while the fires spread.

Some Indigenous leaders are asking for a trial to determine responsibility for the fires, and the response to them. Alex Villca, an Indigenous leader and spokesperson, said:

It is President Evo Morales who should be held accountable. What are these accountabilities going to be? A trial of responsibilities for this number of events that are occurring in the country, this number of violations of Indigenous peoples and also the rights of Mother Nature.

The dry forest understorey ignites while firefighters deploy fire breaks. Ipa Ibañez, Author provided

The dry forest understorey ignites while firefighters deploy fire breaks. Ipa Ibañez, Author provided

President Morales came to power in Bolivia in 2006, on a platform of socialism, Indigenous rights, and environmental protection. He passed the famous “Law of the Rights of Mother Earth” in 2010, which placed the intrinsic value of nature alongside that of humans. His environmental rhetoric has been strong but his policies have been contradictory. Morales has approved widespread deforestation, as well as roads and gas exploration in national parks.

While the fires in the Chiquitano have dominated the media within the country, hundreds more rage across Bolivia, assisted by the recent drought. It’s unclear whether the response to these fires will affect the October election outcome, but sentiments are running high in the country, where more than 70% of people prioritise environmental protection over economic growth.

Bolsonaro and Brazil might grab the headlines, but Bolivia too is now host to a desperately serious humanitarian and environmental situation.

CLAIRE F.R. WORDLEY is a Research Associate, Conservation Evidence, Department of Zoology, University of Cambridge.

THIS ARTICLE WAS ORIGINALLY PUBLISHED ON THE CONVERSATION.