A war resister is a person who resists war. The term can mean
several things: resisting participation in all war, or a specific war,
either before or after enlisting in, being inducted into, or being conscripted into a military force.
History, evolution and etymology of the term
Early usage of the term "war resister" is found in the name of the War Resisters League which was formed in 1923 by men and women who had opposed World War I. The War Resisters League is a section of the London-based War Resisters' International which was founded in Bilthoven, Netherlands, in 1921 under the name "Paco".
In 2008 and 2009, the Parliament of Canada
officially adopted the term "war resister" to include those who are not
necessarily opposed to all war, but who selectively refused to
participate in the Iraq War. This practice was also adopted by various media in Canada at various times.
On November 9, 2010, Canadian writer Peter Smollett referred to people opposing World War I as "war resisters." Among the people he mentioned were Albert Goodwin and Siegfried Sassoon.
In international law, specifically the Handbook on Procedures and Criteria for Determining Refugee Status of the Office of the United Nations High Commissioner for Refugees
(UNHCR), there is discussion of "refugee status after desertion" as
being legitimate under international law. The Handbook states:
171. Not every conviction, genuine though it may be, will constitute a sufficient reason for claiming refugee status after desertion
or draft-evasion. It is not enough for a person to be in disagreement
with his government regarding the political justification for a
particular military action. Where, however, the type of military action,
with which an individual does not wish to be associated, is condemned
by the international community
as contrary to basic rules of human conduct, punishment for desertion
or draft-evasion could, in the light of all other requirements of the
definition, in itself be regarded as persecution.
Canadian law
The federal law-making body of Canada is the Parliament of Canada. The term "war resister" is used in the official documents of the Parliament of Canada: On November 22, 2007, a Canadian Parliamentary Committee "commenced its study of Iraq war resisters" This Committee work resulted in a motion which also used the term "war resisters" and which was passed twice by the House of Commons of Canada: on June 3, 2008, and on March 30, 2009. After the motion passed the first time, the media began to use the term "war resister," also.
There was some controversy when the Canadian Supreme Court
refused to hear the appeals of two American army deserters, Jeremy
Hinzman and Brandon Hughey, whose requests for refugee status were
denied. Both had deserted to Canada in 2004 after learning they were to
be deployed to Iraq. The high court, as usual, gave no reasons for its
refusal.
Earlier the Federal Court and the Federal Court of Appeal upheld
the Immigration and Refugee Board (IRB) findings that the two did not
qualify as Convention refugees. Both faced court martial and up to five years in jail as deserters if
returned. Lawyer Faisal Kutty argued that the IRB and the court appear
to have danced around the politically sensitive issues and existing case
law. Their arguments that they did not want to participate in an
illegal war and that they would be punished for acting on their
conscience was rejected by the IRB. The adjudicators held that they were
not conscientious objectors (because they were not opposed to wars in
general); the U.S. was willing and able to protect them; and that their
treatment would not amount to persecution.
Paragraph 171 of UN Handbook on Procedures and Criteria for
Determining Convention Refugee Status provides that where the type of
military action with which an individual does not wish to be associated
is condemned by the international legal community as contrary to rules
of human conduct, punishment for desertion could be regarded as
persecution.
In denying both claims, the adjudicators opined that the legal
status of the war in Iraq had no bearing on the analysis of paragraph
171. This determination was one of the issues on which the matters were
appealed to the Federal Court, but Justice Anne Mactavish, noted in
separate decisions (Hughey v. Canada [2006] F.C. 421 and Hinzman v.
Canada [2006] F.C. 420) that this question was not an issue before her
and did not have to be decided.
The duo's lawyer, Jeffrey House, says the decisions at both
levels were also based on the erroneous view that American jurisprudence
gives war resisters the right to seek a remedy if they question the
legality of a war. In fact, he argues that this is not true. The
leading case on the "political questions doctrine" which revolves around
whether people can challenge the legality of war based on their
conscience and international law was turned down by the United States
Supreme Court in Callan v. Bush. Given this situation, the U.S. is not
in a position to provide protection to resisters, notes House. House
himself was a war resister.
The existing case law from the Federal Court of Appeal, Al-Maisri
v. Canada [1995] F.C. J. No. 642, appears on point and yet was rejected
by Justice Mactavish as being of "limited assistance." The case
involved a Yemeni who was denied status by the IRB. Al-Maisri
acknowledged he was prepared to fight for Yemen to protect it from
aggression, but was not prepared to fight for Iraq against Kuwait. Yemen
was an Iraqi supporter. The Court of Appeal held that "non-defensive
incursion into foreign territory" was within the ambit of paragraph 171
and overturned the IRB decision. "What is wrong for Saddam Hussein
should be wrong for the Americans as well," says House, a Vietnam-era
draft dodger.
Justice Mactavish held that the legality of the conflict is
irrelevant when analyzing paragraph 171 when "one is considering the
claim of a low-level 'foot soldier'." Yet, Al-Maisri was also a 'foot
soldier.' Justice Mactavish admitted that "given the decision of the
Court of Appeal in Al-Maisri, it is fair to say that the issue is not
entirely free from doubt," and proceeded to certify this question, which
gave the two an automatic right of appeal to the Court of Appeal.
Authorities in Canada and the U.S closely monitored the
politically sensitive case. Indeed, the case became the proverbial
public relations "hot potato" for the U.S. At the initial hearing, a
former U.S. Marine testifying in Hinzman's support stated that American
soldiers in Iraq routinely violated international law by killing unarmed
civilians, including women and children. Affidavits from two
international law professors confirming the illegality of the war and
reports from Human Rights Watch and the International Committee of the
Red Cross documenting the abuses and violations were also filed.
According to philosophy professor R. W. Hepburn: "To move towards the
objectivist pole is to argue that moral judgements can be rationally
defensible, true or false, that there are rational procedural tests for
identifying morally impermissible actions, or that moral values exist
independently of the feeling-states of individuals at particular times."
"if we adopt the principle of universality:
if an action is right (or wrong) for others, it is right (or wrong) for
us. Those who do not rise to the minimal moral level of applying to
themselves the standards they apply to others—more stringent ones, in
fact—plainly cannot be taken seriously when they speak of
appropriateness of response; or of right and wrong, good and evil."
The United Nations' Universal Declaration of Human Rights
can be read as assuming characteristics and attributes akin to moral
universalism. The drafting committee of the Universal Declaration did
assume, or at least aspired to, a "universal" approach to articulating
international human rights.
Although the Declaration has undeniably come to be accepted throughout
the world as a cornerstone of the international system for the
protection of human rights, a belief among some that the Universal
Declaration does not adequately reflect certain important worldviews has
given rise to more than one supplementary declaration, such as the Cairo Declaration on Human Rights in Islam and the Bangkok Declaration.
Global environmental treaties may also assume and present a moral universalism. The United Nations Framework Convention on Climate Change
is founded upon the "common heritage of mankind". Protecting this
heritage is presented in the treaty as a shared moral duty requiring
protective actions based on "common but differentiated
responsibilities". This has been criticized as anthropocentric and state-centric but it does assert universal goals.
Similarly, divine command theory
presents a form of universalism, by way of the unconditional morality
of God's commandments. It revolves around the idea that morality is
synonymous with following God's commands. While various religions may
have Gods that endorse different beliefs and behaviors, divine command
theory encompasses all instances of a deity dictating a society's
morals. Plato's "Euthyphro dilemma" is a dialogue written to point out the inconsistencies of this philosophy.
Modern studies and measurement
There is a body of work studying moral universalism using
experimental and survey data in Economics, recently reinvigorated by
Harvard Economist Ben Enke.
The body broadly attempts to describe correlates with universalist
preferences and to study the moral origins of political preferences or
polarization. These efforts can be attributed as loosely inspired by the
work of social psychologist, Jonathan Haidt, and his Moral Foundations Theory.
The Moral Foundations theory, developed by Jonathan Haidt
and colleagues, proposes that there are "intuitive ethics," or morals
that individuals subscribe to within cultures. There are five
foundations that a person's behaviors tend to adhere to: care/harm,
fairness/cheating, loyalty/betrayal, authority/subversion, and
sanctity/degradation. Haidt argues that these morals are cross-cultural,
and alignment with them is present at birth. Of note, the Moral Foundations Theory does not assert that every
culture has the same morals, but rather each has developed their own set
of acceptable behaviors, and there tends to be overlaps in the
aforementioned areas listed earlier.
Universalism and politics
Measurement regarding universalism and politics typically seeks to explain political divides from the moral origins
of their supporters. Enke et al. have published a number of studies,
including their canonical study, where they find that heterogeneity in
universalism descriptively explains why the left and right both
simultaneously support and oppose different types of government
spending. They find that you can explain the left-right divide on topics such as
redistribution through the level and quality of universalism in their
respective politics (e.g., redistribution to US veterans, which is more
morally loyalist, compared to redistribution via foreign aid). They find
the political left to be broadly more universalistic. Haidt too has
written about how his (broader) Moral Foundations theory can be applied
to modern US politics.
Enke and his coauthors also find that universalism is significantly
related to observables: older people, men, the rich, the rural, and the
religious exhibit less moral universalism. Moreover, universalists donate less money but to more global
recipients. Behaviorally, universalists have fewer friends, spend less
time with them, and feel more lonely.
These studies also allow us to compare the prevalence of
universalism across countries and cultures. A large, cross-country
survey study finds that socioeconomic experiences determine levels of
universalism, with experience of democracy greatly helping. Anthropologists at the University of Oxford published a study in 2019 examining 60 different cultures and their principles. This study was conducted by reviewing ethnographic
content from each culture. Seven fundamentals were identified
beforehand, and historic writings were analyzed to search for either
positive or negative moral valence of each one. It was found that 99.9%
of the time, these seven behaviors were considered "moral": helping kin,
helping group, reciprocating, being brave, respecting superiors,
dividing resources, and respecting property. These principles appeared across all cultures studied, and only one
counterexample was found: an instance of the "respecting property" value
clashing with "being brave."
Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among many individuals. By estimating the overall risk of health risk and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization, such as a government agency, private business, or not-for-profit entity.
According to the Health Insurance Association of America,
health insurance is defined as "coverage that provides for the payments
of benefits as a result of sickness or injury. It includes insurance
for losses from accident, medical expense, disability, or accidental
death and dismemberment".
A health insurance policy is an insurance contract
between an insurance provider (e.g. an insurance company or a
government) and an individual or his/her sponsor (that is an employer or
a community organization). The contract can be renewable (annually,
monthly) or lifelong in the case of private insurance. It can also be
mandatory for all citizens in the case of national plans. The type and
amount of health care costs that will be covered by the health insurance
provider are specified in writing, in a member contract or "Evidence of
Coverage" booklet for private insurance, or in a national health policy for public insurance.
Funding and obligations
Health expenditure funding types
There are two types of health insurance – tax payer-funded and private-funded. A private-funded insurance plan example includes an employer-sponsored self-funded ERISA
(Employee Retirement Income Security Act of 1974) plan. Typically,
these companies promote themselves as having ties to major insurance
providers. However, in the context of an ERISA plan, these insurance
companies do not actively participate in insurance practices; instead,
they handle administrative tasks. Consequently, ERISA plans are exempt
from state regulations and fall under federal jurisdiction, overseen by
the US Department of Labor (USDOL). Specific details about benefits or
coverage can be found in the Summary Plan Description (SPD). Should
there be a need for an appeal, the process typically involves initiating
it through the insurance company and then reaching out to the
Employer's Plan Fiduciary. If a resolution is still not achieved, the
decision can be escalated to the USDOL for review to ensure compliance
with ERISA regulations, and, if necessary, legal action can be taken by
filing a lawsuit in federal court. Health insurance can be combined with
publicly funded health care and medical savings accounts.
The individual insured person's obligations may take several forms:
Premium:
The amount the policy-holder or their sponsor (e.g. an employer) pays
to the health plan to purchase health coverage. (US specific) According
to the healthcare law, a premium is calculated using 5 specific factors
regarding the insured person. These factors are age, location, tobacco
use, individual vs. family enrollment, and which plan category the
insured chooses. Under the Affordable Care Act, the government pays a tax credit to
cover part of the premium for persons who purchase private insurance
through the Insurance Marketplace.
Deductible: The amount that the insured must pay out-of-pocket
before the health insurer pays its share. For example, policy-holders
might have to pay a $7500 deductible per year, before any of their
health care is covered by the health insurer. It may take several
doctor's visits or prescription refills before the insured person
reaches the deductible and the insurance company starts to pay for care.
Furthermore, most policies do not apply co-pays for doctor's visits or
prescriptions against the insured's deductible.
Co-payment:
The amount that the insured person must pay out of pocket before the
health insurer pays for a particular visit or service. For example, an
insured person might pay a $45 co-payment for a doctor's visit, or to
obtain a prescription. A co-payment must be paid each time a particular
service is obtained.
Coinsurance:
Instead of, or in addition to, paying a fixed amount up front (a
co-payment), the co-insurance is a percentage of the total cost that an
insured person may also pay. For example, the member might have to pay
20% of the cost of a surgery over and above a co-payment, while the
insurance company pays the other 80%. If there is an upper limit on
coinsurance, the policy-holder could end up owing very little, or a
great deal, depending on the actual costs of the services they obtain.
Exclusions: Not all services are covered. Billed items like disposables, taxes, etc.are excluded from admissible claim. The insured are generally expected
to pay the full cost of non-covered services out of their own funds.
Coverage limits: Some health insurance policies only pay for health
care up to a certain dollar amount. The insured person may be expected
to pay any charges in excess of the health plan's maximum payment for a
specific service. In addition, some insurance company schemes have
annual or lifetime coverage maxima. In these cases, the health plan will
stop payment when they reach the benefit maximum, and the policy-holder
must pay all remaining costs.
Out-of-pocket maximum: Similar to coverage limits, except that in
this case, the insured person's payment obligation ends when they reach
the out-of-pocket maximum, and health insurance pays all further covered
costs. Out-of-pocket maximum can be limited to a specific benefit
category (such as prescription drugs) or can apply to all coverage
provided during a specific benefit year.
Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer.
In-Network Provider: (U.S. term) A health care provider on a list of
providers preselected by the insurer. The insurer will offer discounted
coinsurance or co-payments, or additional benefits, to a plan member to
see an in-network provider. Generally, providers in network are
providers who have a contract with the insurer to accept rates further
discounted from the "usual and customary" charges the insurer pays to
out-of-network providers.
Out-of-Network Provider: A health care provider that has not
contracted with the plan. If using an out-of-network provider, the
patient may have to pay full cost of the benefits and services received
from that provider. Even for emergency services, out-of-network
providers may bill patients for some additional costs associated.
Prior Authorization: A certification or authorization that an
insurer provides prior to medical service occurring. Obtaining an
authorization means that the insurer is obligated to pay for the
service, assuming it matches what was authorized. Many smaller, routine services do not require authorization.
Formulary: the list of drugs that an insurance plan agrees to cover.
Explanation of benefits:
A document that may be sent by an insurer to a patient explaining what
was covered for a medical service, and how payment amount and patient
responsibility amount were determined. In the case of emergency room billing, patients are notified within 30
days post service. Patients are rarely notified of the cost of emergency
room services in-person due to patient conditions and other logistics
until receipt of this letter.
Prescription drug plans are a form of insurance offered through some
health insurance plans. In the U.S., the patient usually pays a
copayment and the prescription drug insurance part or all of the balance
for drugs covered in the formulary of the plan. Such plans are routinely part of national health insurance programs. For example, in the province of Quebec, Canada,
prescription drug insurance is universally required as part of the
public health insurance plan, but may be purchased and administered
either through private or group plans, or through the public plan.
Some, if not most, health care providers in the United States
will agree to bill the insurance company if patients are willing to sign
an agreement that they will be responsible for the amount that the
insurance company does not pay. The insurance company pays out of
network providers according to "reasonable and customary" charges, which
may be less than the provider's usual fee. The provider may also have a
separate contract with the insurer to accept what amounts to a
discounted rate or capitation to the provider's standard charges. It
generally costs the patient less to use an in-network provider.
Health Expenditure per capita (in PPP-adjustedUS$) among several OECD member nations. Data source: OECD's iLibraryLife Expectancy of the total population at birth among several OECD member nations. Data source: OECD's iLibrary
The Commonwealth Fund, in its annual survey, "Mirror, Mirror on the
Wall", compares the performance of the health care systems in Australia, New Zealand, the United Kingdom, Germany,
Canada and the U.S. Its 2007 study found that, although the U.S. system
is the most expensive, it consistently under-performs compared to the
other countries. One difference between the U.S. and the other countries in the study is
that the U.S. is the only country without universal health insurance
coverage.
The Commonwealth Fund completed its thirteenth annual health policy survey in 2010. A study of the survey "found significant differences in access, cost
burdens, and problems with health insurance that are associated with
insurance design." Of the countries surveyed, the results indicated that people in the
United States had more out-of-pocket expenses, more disputes with
insurance companies than other countries, and more insurance payments
denied; paperwork was also higher although Germany had similarly high
levels of paperwork.
The Australian public health system is called Medicare,
which provides free universal access to hospital treatment and
subsidised out-of-hospital medical treatment. It is funded by a 2% tax
levy on all taxpayers, an extra 1% levy on high income earners, as well
as general revenue.
The private health system is funded by a number of private health insurance organizations. The largest of these is Medibank, which was, until 2014, a government-owned entity, when it was privatized and listed on the Australian Securities Exchange.
Australian health funds can be either 'for profit' including Bupa and nib; 'mutual' including Australian Unity; or 'non-profit' including GMHBA, HCF and HBF.
Some, such as Police Health, have membership restricted to particular
groups, but the majority have open membership. Membership to most health
funds is now also available through comparison websites. These
comparison sites operate on a commission-basis by agreement with their
participating health funds. The Private Health Insurance Ombudsman also
operates a free website that allows consumers to search for and compare
private health insurers' products, which includes information on price
and level of cover.
Most aspects of private health insurance in Australia are regulated by the Private Health Insurance Act 2007. Complaints and reporting of the private health industry is carried out by an independent government agency, the Private Health Insurance Ombudsman.
The ombudsman publishes an annual report that outlines the number and
nature of complaints per health fund compared to their market share
The private health system in Australia operates on a "community
rating" basis, whereby premiums do not vary solely because of a person's
previous medical history, the current state of health, or (generally
speaking) their age (but see Lifetime Health Cover below). Balancing
this are waiting periods, in particular for pre-existing conditions
(usually referred to within the industry as PEA, which stands for
"pre-existing ailment"). Funds are entitled to impose a waiting period
of up to 12 months on benefits for any medical condition the signs and
symptoms of which existed during the six months ending on the day the
person first took out insurance. They are also entitled to impose a
12-month waiting period for benefits for treatment relating to an
obstetric condition, and a 2-month waiting period for all other benefits
when a person first takes out private insurance. Funds have the
discretion to reduce or remove such waiting periods in individual cases.
They are also free not to impose them, to begin with, but this would
place such a fund at risk of "adverse selection", attracting a
disproportionate number of members from other funds, or from the pool of
intending members who might otherwise have joined other funds. It would
also attract people with existing medical conditions, who might not
otherwise have taken out insurance at all because of the denial of
benefits for 12 months due to the PEA Rule. The benefits paid out for
these conditions would create pressure on premiums for all the fund's
members, causing some to drop their membership, which would lead to
further rises in premiums, and a vicious cycle of higher
premiums-leaving members would ensue.
The Government of Australia has introduced a number of incentives to encourage adults to take out private hospital insurance. These include:
Lifetime Health Cover: If a person has not taken out
private hospital cover by 1 July after their 31st birthday, then when
(and if) they do so after this time, their premiums must include a
loading of 2% per annum for each year they were without hospital cover.
Thus, a person taking out private cover for the first time at age 40
will pay a 20 percent loading. The loading is removed after 10 years of
continuous hospital cover. The loading applies only to premiums for
hospital cover, not to ancillary (extras) cover.
Medicare Levy Surcharge: People whose taxable income is
greater than a specified amount ( from 2025-26 financial year $101,000
for singles and $202,000 for couples and who do not have an adequate level of private hospital cover must
pay a 1% surcharge on top of the standard 1.5% Medicare Levy. The
rationale is that if the people in this income group are forced to pay
more money one way or another, most would choose to purchase hospital
insurance with it, with the possibility of a benefit if they need
private hospital treatment – rather than pay it in the form of extra tax
as well as having to meet their own private hospital costs.
The Australian government announced in May 2008 that it proposes
to increase the thresholds, to $100,000 for singles and $150,000 for
families. These changes require legislative approval. A bill to change
the law has been introduced but was not passed by the Senate. An amended version was passed on 16 October 2008. There have been
criticisms that the changes will cause many people to drop their private
health insurance, causing a further burden on the public hospital
system, and a rise in premiums for those who stay with the private
system. Other commentators believe the effect will be minimal.
Private Health Insurance Rebate: The government subsidises
the premiums for all private health insurance cover, including hospital
and ancillary (extras), by 10%, 20% or 30%, depending on age. The Rudd Government
announced in May 2009 that as of July 2010, the Rebate would become
means-tested, and offered on a sliding scale. While this move (which
would have required legislation) was defeated in the Senate at the time,
in early 2011 the Gillard Government announced plans to reintroduce the
legislation after the Opposition loses the balance of power in the
Senate. The ALP and Greens have long been against the rebate, referring to it as "middle-class welfare".
As per the Constitution of Canada,
health care is mainly a provincial government responsibility in Canada
(the main exceptions being federal government responsibility for
services provided to aboriginal peoples covered by treaties, the Royal Canadian Mounted Police, the armed forces, and Members of Parliament).
Consequently, each province administers its own health insurance
program. The federal government influences health insurance by virtue of
its fiscal powers – it transfers cash and tax points to the provinces
to help cover the costs of the universal health insurance programs.
Under the Canada Health Act,
the federal government mandates and enforces the requirement that all
people have free access to what are termed "medically necessary
services," defined primarily as care delivered by physicians or in
hospitals, and the nursing component of long-term residential care. If
provinces allow doctors or institutions to charge patients for medically
necessary services, the federal government reduces its payments to the
provinces by the amount of the prohibited charges. Collectively, the
public provincial health insurance systems in Canada are frequently
referred to as Medicare. This public insurance is tax-funded out of general government revenues, although British Columbia and Ontario
levy a mandatory premium with flat rates for individuals and families
to generate additional revenues – in essence, a surtax. Private health
insurance is allowed, but in six provincial governments only for
services that the public health plans do not cover (for example,
semi-private or private rooms in hospitals and prescription drug plans).
Four provinces allow insurance for services also mandated by the Canada Health Act,
but in practice, there is no market for it. All Canadians are free to
use private insurance for elective medical services such as laser vision
correction surgery, cosmetic surgery, and other non-basic medical
procedures. Some 65% of Canadians have some form of supplementary
private health insurance; many of them receive it through their
employers. Private-sector services not paid for by the government account for nearly 30 percent of total health care spending.
In 2005, the Supreme Court of Canada ruled, in Chaoulli v. Quebec, that the province's prohibition on private insurance for health care already insured by the provincial plan violated the Quebec Charter of Rights and Freedoms, and in particular, the sections dealing with the right to life and security,
if there were unacceptably long wait times for treatment, as was
alleged in this case. The ruling has not changed the overall pattern of
health insurance across Canada, but has spurred on attempts to tackle
the core issues of supply and demand and the impact of wait times.
In 2020 in Cyprus introduced the General Healthcare System
(GHS, also known as GESY) which is an independent insurance fund
through which clinics, private doctors, pharmacists, laboratories,
microbiological laboratories, and physiotherapists will be paid so that
they can offer medical care to permanent residents of Cyprus who will be
paying contributions to this fund.
In addition to GESY, more than 12 local and international insurance companies (e.g. Bupa, Aetna, Cigna, Metlife)
provide individual and group medical insurance plans. The plans are
divided into two main categories plans providing coverage from inpatient
expenses (i.e. hospitalization, operations) and plans covering
inpatient and outpatient expenses (such as doctor visits, medications,
physio-therapies).
The national system of health insurance was instituted in 1945, just
after the end of the Second World War. It was a compromise between Gaullist and Communist
representatives in the French parliament. The Conservative Gaullists
were opposed to a state-run healthcare system, while the Communists were
supportive of a complete nationalisation of health care along a British Beveridge model.
The resulting programme is profession-based: all people working
are required to pay a portion of their income to a not-for-profit health
insurance fund, which mutualizes the risk of illness, and which
reimburses medical expenses at varying rates. Children and spouses of
insured people are eligible for benefits, as well. Each fund is free to
manage its own budget, and used to reimburse medical expenses at the
rate it saw fit, however following a number of reforms in recent years,
the majority of funds provide the same level of reimbursement and
benefits.
The government has two responsibilities in this system.
The first government responsibility is the fixing of the rate at
which medical expenses should be negotiated, and it does so in two
ways: The Ministry of Health directly negotiates prices of medicine with
the manufacturers, based on the average price of sale observed in
neighboring countries. A board of doctors and experts decides if the
medicine provides a valuable enough medical benefit to be reimbursed
(most medicine is reimbursed, including homeopathy). In parallel, the
government fixes the reimbursement rate for medical services: this means
that a doctor is free to charge the fee that he wishes for a
consultation or an examination, but the social security system will only
reimburse it at a pre-set rate. These tariffs are set annually through
negotiation with doctors' representative organizations'.
The second government responsibility is oversight of the
health-insurance funds, to ensure that they are correctly managing the
sums they receive, and to ensure oversight of the public hospital
network.
Today, this system is more or less intact. All citizens and legal foreign residents of France
are covered by one of these mandatory programs, which continue to be
funded by worker participation. However, since 1945, a number of major
changes have been introduced. Firstly, the different health care funds
(there are five: General, Independent, Agricultural, Student, Public
Servants) now all reimburse at the same rate. Secondly, since 2000, the
government now provides health care to those who are not covered by a
mandatory regime (those who have never worked and who are not students,
meaning the very rich or the very poor). This regime, unlike the
worker-financed ones, is financed via general taxation and reimburses at
a higher rate than the profession-based system for those who cannot
afford to make up the difference. Finally, to counter the rise in health
care costs, the government has installed two plans, (in 2004 and 2006),
which require insured people to declare a referring doctor in order to
be fully reimbursed for specialist visits, and which installed a
mandatory co-pay of €1 for a doctor visit, €0.50 for each box of
medicine prescribed, and a fee of €16–18 per day for hospital stays and
for expensive procedures.
An important element of the French insurance system is
solidarity: the more ill a person becomes, the less the person pays.
This means that for people with serious or chronic illnesses, the
insurance system reimburses them 100% of expenses, and waives their
co-pay charges.
Finally, for fees that the mandatory system does not cover, there
is a large range of private complementary insurance plans available.
The market for these programs is very competitive, and often subsidised
by the employer, which means that premiums are usually modest. 85% of
French people benefit from complementary private health insurance.
Beginning with 10% of blue-collar workers in 1885, mandatory
insurance has expanded; in 2009, insurance was made mandatory on all
citizens, with private health insurance for the self-employed or above
an income threshold. As of 2016, 85% of the population is covered by the compulsory Statutory Health Insurance (SHI) (Gesetzliche Krankenversicherung or GKV), with the remainder covered by private insurance (Private Krankenversicherung or PKV). Germany's health care system was 77% government-funded and 23% privately funded as of 2004. While public health insurance contributions are based on the
individual's income, private health insurance contributions are based on
the individual's age and health condition.
Reimbursement is on a fee-for-service
basis, but the number of physicians allowed to accept Statutory Health
Insurance in a given locale is regulated by the government and
professional societies.
Co-payments were introduced in the 1980s in an attempt to prevent
over utilization. The average length of hospital stay in Germany has
decreased in recent years from 14 days to 9 days, still considerably
longer than average stays in the United States (5 to 6 days). Part of the difference is that the chief consideration for hospital
reimbursement is the number of hospital days as opposed to procedures or
diagnosis. Drug costs have increased substantially, rising nearly 60%
from 1991 through 2005. Despite attempts to contain costs, overall
health care expenditures rose to 10.7% of GDP in 2005, comparable to
other western European nations, but substantially less than that spent
in the U.S. (nearly 16% of GDP).
Germans are offered three kinds of social security insurance
dealing with the physical status of a person and which are co-financed
by employer and employee: health insurance, accident insurance, and
long-term care insurance. Long-term care insurance (Gesetzliche Pflegeversicherung) emerged in 1994 and is mandatory. Accident insurance
(gesetzliche Unfallversicherung) is covered by the employer and
basically covers all risks for commuting to work and at the workplace.
Greece
The National Health System in Greece covers both out and in-patient treatment. The out-patient treatment is carried out by social administrative structures as following:
EOPPY (National Organization for the Provision of Health Services): contracted private healthcare providers
PEDY (National Primary Healthcare Network) units: public healthcare
State hospitals, rural and regional medical units, health centers of the ESY (National Health System)
Private health professionals: Medical professionals and services not contracted with EOPYY.
The in-patient treatment is carried out by:
State hospitals of the National Health System (ESY).
Private Clinics contracted with the National Health Carrier (EOPYY)
Private hospitals and clinics that are not contracted with the National Health Carrier.
In Greece anyone can cover the hospitalization expenses using a
private insurance policy, that can be bought by any of the local or
multinational insurance companies that operate in the region (e.g.
Metlife, Interamerican, Aetna, IMG).
In India, provision of healthcare services and their efficiency
varies state-wise. Public health services are prominent in most of the
regions with the national government playing an important role in
funding, framing and implementing policies and operating public health
insurances.
There are three major types of insurance programs available in Japan:
Employee Health Insurance (健康保険 Kenkō-Hoken), National Health Insurance
(国民健康保険 Kokumin-Kenkō-Hoken), and the Late-stage Elderly Medical System
(後期高齢医療制度 Kouki-Kourei-Iryouseido). Although private health insurance is available, all Japanese citizens,
permanent residents, and non-Japanese with a visa lasting one year or
longer are required to be enrolled in either National Health Insurance
or Employee Health Insurance. National Health Insurance is designed for
those who are not eligible for any employment-based health insurance
program. The Late-stage Elderly Medical System is designed for people
who are age 75 and older.
National Health Insurance is organised on a household basis. Once
a household has applied, the entire family is covered. Applicants
receive a health insurance card, which must be used when receiving
treatment at a hospital. There is a required monthly premium, but
co-payments are standardized so payers are only expected to cover ten to
thirty percent of the cost, depending on age. If out-of-pocket costs exceed pre-determined limits, payers may apply for a rebate from the National Health Insurance program.
Employee Health Insurance covers diseases, injuries, and death
regardless of whether an incident occurred at a workplace. Employee
Health Insurance covers a maximum of 180 days of medical care per year
for work-related diseases or injuries and 180 days per year for other
diseases or injuries. Employers and employees must contribute evenly to
be covered by Employee Health Insurance.
The Late-stage Elderly Medical System began in 1983 following the
Health Care for the Aged Law of 1982. It allowed many health insurance
systems to offer financial assistance to elderly people. There is a
medical coverage fee. To be eligible, those insured must be either:
older than 70, or older than 65 with a recognized disability. The Late-stage Elderly Medical System includes preventive and standard medical care.
healthcare expenditure in Japan by age group
Issues of the healthcare system
Due to Japan's aging population,
the Late-stage Elderly Medical System represents one third of the
country's total healthcare cost. When retiring employees shift from
Employee Health Insurance to the Late-stage Elderly Medical System, the
national cost of health insurance is expected to increase since
individual healthcare costs tend to increase with age.
In 2006, a new system of health insurance came into force in the
Netherlands. This new system avoids the two pitfalls of adverse
selection and moral hazard associated with traditional forms of health
insurance by using a combination of regulation and insurance equalization pool.
Moral hazard is avoided by mandating that insurance companies provide
at least one policy that meets a government set minimum standard level
of coverage, and all adult residents are obliged by law to purchase this
coverage from an insurance company of their choice. All insurance
companies receive funds from the equalization pool to help cover the
cost of this government-mandated coverage. This pool is run by a
regulator which collects salary-based contributions from employers,
which make up about 50% of all health care funding, and funding from the
government to cover people who cannot afford health care, which makes
up an additional 5%.
The remaining 45% of health care funding comes from insurance
premiums paid by the public, for which companies compete on price,
though the variation between the various competing insurers is only
about 5%. However, insurance companies are free to sell additional
policies to provide coverage beyond the national minimum. These policies
do not receive funding from the equalization pool but cover additional
treatments, such as dental procedures and physiotherapy, which are not
paid for by the mandatory policy.
Funding from the equalization pool is distributed to insurance
companies for each person they insure under the required policy.
However, high-risk individuals get more from the pool, and low-income
persons and children under 18 have their insurance paid for entirely.
Because of this, insurance companies no longer find insuring high-risk
individuals an unappealing proposition, avoiding the potential problem
of adverse selection.
Insurance companies are not allowed to have co-payments, caps, or
deductibles, or deny coverage to any person applying for a policy, or
charge anything other than their nationally set and published standard
premiums. Therefore, every person buying insurance will pay the same
price as everyone else buying the same policy, and every person will get
at least the minimum level of coverage. This applies to all people
permanently living and working in the Netherlands. International
students that move to the Netherlands for study purposes have to take
out compulsory Dutch health insurance if they also decide to work
(zero-hour contracts included) or do a paid internship during their
stay. In that case, they'll need to take out the compulsory basic
package of Dutch health insurance. Additional insurance is optional,
depending on the student's personal needs.
Since 1974, New Zealand has had a system of universal no-fault health insurance for personal injuries through the Accident Compensation Corporation
(ACC). The ACC scheme covers most of the costs of related to treatment
of injuries acquired in New Zealand (including overseas visitors)
regardless of how the injury occurred, and also covers lost income (at
80 percent of the employee's pre-injury income) and costs related to
long-term rehabilitation, such as home and vehicle modifications for
those seriously injured. Funding from the scheme comes from a
combination of levies on employers' payroll (for work injuries), levies
on an employee's taxable income (for non-work injuries to salary
earners), levies on vehicle licensing fees and petrol (for motor vehicle
accidents), and funds from the general taxation pool (for non-work
injuries to children, senior citizens, unemployed people, overseas
visitors, etc.)
Rwanda is one of a handful of low income countries
that has implemented community-based health insurance schemes in order
to reduce the financial barriers that prevent poor people from seeking
and receiving needed health services. This scheme has helped reach 90%
of the country's population with health care coverage.
Singaporeans have one of the longest life expectancy at birth
in the world. During this long life, encountering uncertain situations
requiring hospitalization are inevitable. Health insurance or medical
insurance cover high healthcare costs during hospitalization.
Health insurance for Singapore Citizens and Permanent Residents
MediShield Life,
is a universal health insurance covering all Singapore Citizens and
Permanent Residents. MediShield Life covers hospitalization costs for a
stay in ward B2 or C in a Public hospital. For the hospitalization in a
Private hospital, or in ward A or B1 in Public hospital, MediShield Life
coverage is pegged to B2 or C ward prices and insured is required to
pay the remaining bill amount. This remaining bill amount can be paid
using MediSave
but limits are applied on the MediSave usage. MediShield Life does not
cover overseas medical expenses and the treatment of serious
pre-existing illnesses for which one has been receiving treatment during
the 12 months before the start of the MediShield Life coverage.
MediShield Life also does not cover treatment of congenital anomalies
(medical conditions that are present at birth), cosmetic surgery,
pregnancy-related charges and mental illness.
As the MediShield Life benefits are capped for B2 or C ward
hospitalization in public hospitals, Integrated Shield plans provide
coverage for the hospitalization in private hospitals, or ward A or B1
in public hospitals. Integrated Shield insurance plans cover large hospitalization bills for Private hospitals or, ward A or B1. However, insured is still required to pay a portion of the bill amount.
This is in accordance with Singapore's healthcare philosophy which
promotes personal responsibility with getting individuals to share the
cost of healthcare. With this philosophy, deductible, co-insurance and
peroration are applied on most of the Health Insurance plans in
Singapore. Such health insurance plans provide an option to purchase a
health insurance rider to cover these charges.
Health insurance for Foreigners in Singapore
Unlike Singapore citizens and permanent residents, foreigners are
not automatically covered by the MediShield Life. Foreigners can
purchase the health insurance plans from several life insurers in
Singapore.
South Korea's life expectancy at birth was 82.7 years in 2017, higher than the OECD
average of 80.8. Men's life expectancy was 79.7 years, higher than the
OECD average of 78.1 years, and women's life expectancy was 85.7 years,
higher than the average of 83.4 years.
Health care in South Korea is provided by the National Health Insurance
(NHI), which is mandatory. Anyone residing in South Korea, regardless
of nationality or occupation, can purchase this insurance.
Healthcare in Switzerland is universal and is regulated by the Swiss Federal Law on Health Insurance. Health insurance is compulsory for all persons residing in Switzerland (within three months of taking up residence or being born in the country). It is therefore the same throughout the country and avoids double
standards in healthcare. Insurers are required to offer this basic
insurance to everyone, regardless of age or medical condition. They are
not allowed to make a profit off this basic insurance, but can on
supplemental plans.
The universal compulsory coverage provides for treatment in case
of illness or accident and pregnancy. Health insurance covers the costs
of medical treatment, medication and hospitalization of the insured.
However, the insured person pays part of the costs up to a maximum,
which can vary based on the individually chosen plan, premiums are then
adjusted accordingly. The whole healthcare system is geared towards to
the general goals of enhancing general public health and reducing costs
while encouraging individual responsibility.
The Swiss healthcare system is a combination of public,
subsidized private and totally private systems. Insurance premiums vary
from insurance company to company, the excess level individually chosen (franchise),
the place of residence of the insured person and the degree of
supplementary benefit coverage chosen (complementary medicine, routine
dental care, semi-private or private ward hospitalization, etc.).
The insured person has full freedom of choice among the
approximately 60 recognized healthcare providers competent to treat
their condition (in their region) on the understanding that the costs
are covered by the insurance up to the level of the official tariff.
There is freedom of choice when selecting an insurance company to which
one pays a premium, usually on a monthly basis. The insured person pays
the insurance premium for the basic plan up to 8% of their personal
income. If a premium is higher than this, the government gives the
insured person a cash subsidy to pay for any additional premium.
The compulsory insurance can be supplemented by private
"complementary" insurance policies that allow for coverage of some of
the treatment categories not covered by the basic insurance or to
improve the standard of room and service in case of hospitalization.
This can include complementary medicine, routine dental treatment and
private ward hospitalization, which are not covered by the compulsory
insurance.
As far as the compulsory health insurance is concerned, the
insurance companies cannot set any conditions relating to age, sex or
state of health for coverage. Although the level of premium can vary
from one company to another, they must be identical within the same
company for all insured persons of the same age group and region,
regardless of sex or state of health. This does not apply to
complementary insurance, where premiums are risk-based.
Switzerland has an infant mortality rate of about 3.6 out of 1,000. The general life expectancy in 2012 was for men 80.5 years compared to 84.7 years for women. These are the world's best figures.
The UK's National Health Service (NHS) is a publicly funded healthcare
system that provides coverage to everyone normally resident in the UK.
It is not strictly an insurance system because (a) there are no premiums
collected, (b) costs are not charged at the patient level and (c) costs
are not pre-paid from a pool. However, it does achieve the main aim of
insurance which is to spread financial risk arising from ill-health. The costs of running the NHS (est. £104 billion in 2007–8) are met directly from general taxation. The NHS provides the majority of health care in the UK, including primary care, in-patient care, long-term health care, ophthalmology, and dentistry.
Private health care has continued parallel to the NHS, paid for
largely by private insurance, but it is used by less than 8% of the
population, and generally as a top-up to NHS services.
There are many treatments that the private sector does not provide. For
example, health insurance on pregnancy is generally not covered or covered with restricting clauses. Typical exclusions for Bupa schemes (and many other insurers) include:
aging, menopause and puberty; AIDS/HIV; allergies or allergic
disorders; birth control, conception, sexual problems and sex changes;
chronic conditions; complications from excluded or restricted
conditions/ treatment; convalescence, rehabilitation and general nursing
care ; cosmetic, reconstructive or weight loss treatment; deafness;
dental/oral treatment (such as fillings, gum disease, jaw shrinkage,
etc.); dialysis; drugs and dressings for out-patient or take-home use† ;
experimental drugs and treatment; eyesight; HRT and bone densitometry;
learning difficulties, behavioural and developmental problems; overseas
treatment and repatriation; physical aids and devices; pre-existing or
special conditions; pregnancy and childbirth; screening and preventive
treatment; sleep problems and disorders; speech disorders; temporary
relief of symptoms. († = except in exceptional circumstances)
There are a number of other companies in the United Kingdom which include, among others, Chubb Limited, Axa, Aviva, Bupa, Groupama Healthcare, WPA and VitalityHealth. Similar exclusions apply, depending on the policy which is purchased.
In 2009, the main representative body of British Medical
physicians, the British Medical Association, adopted a policy statement
expressing concerns about developments in the health insurance market in
the UK. In its Annual Representative Meeting which had been agreed
earlier by the Consultants Policy Group (i.e. Senior physicians)
stating that the BMA was "extremely concerned that the policies of some
private healthcare insurance companies are preventing or restricting
patients exercising choice about (i) the consultants who treat them;
(ii) the hospital at which they are treated; (iii) making top up
payments to cover any gap between the funding provided by their
insurance company and the cost of their chosen private treatment." It
went in to "call on the BMA to publicise these concerns so that patients
are fully informed when making choices about private healthcare
insurance." The practice of insurance companies deciding which consultant a patient
may see as opposed to GPs or patients is referred to as Open Referral. The NHS offers patients a choice of hospitals and consultants and does not charge for its services.
The private sector has been used to increase NHS capacity despite
a large proportion of the British public opposing such involvement. According to the World Health Organization,
government funding covered 86% of overall health care expenditures in
the UK as of 2004, with private expenditures covering the remaining 14%.
Nearly one in three patients receiving NHS hospital treatment is
privately insured and could have the cost paid for by their insurer.
Some private schemes provide cash payments to patients who opt for NHS
treatment, to deter use of private facilities. A report, by private
health analysts Laing and Buisson, in November 2012, estimated that more
than 250,000 operations were performed on patients with private medical
insurance each year at a cost of £359 million. In addition, £609
million was spent on emergency medical or surgical treatment. Private
medical insurance does not normally cover emergency treatment but
subsequent recovery could be paid for if the patient were moved into a
private patient unit.
On the 1st of August, 2018 the DHHS issued a final rule which made federal changes to Short-Term, Limited-Duration Health Insurance (STLDI) which lengthened the maximum contract term to 364 days and renewal for up to 36 months. This new rule, in combination with the expiration of the penalty for the Individual Mandate of the Affordable Care Act, has been the subject of independent analysis.
The United States health care system relies heavily on private
health insurance, which is the primary source of coverage for most
Americans. As of 2018, 68.9% of American adults had private health
insurance, according to The Center for Disease Control and Prevention. The Agency for Healthcare Research and Quality
(AHRQ) found that in 2011, private insurance was billed for 12.2
million U.S. inpatient hospital stays and incurred approximately $112.5
billion in aggregate inpatient hospital costs (29% of the total national
aggregate costs). Public programs provide the primary source of coverage for most senior
citizens and for low-income children and families who meet certain
eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors and certain disabled individuals; and Medicaid,
funded jointly by the federal government and states but administered at
the state level, which covers certain very low income children and
their families. Together, Medicare and Medicaid accounted for
approximately 63 percent of the national inpatient hospital costs in
2011. SCHIP
is a federal-state partnership that serves certain children and
families who do not qualify for Medicaid but who cannot afford private
coverage. Other public programs include military health benefits
provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals.
In the late 1990s and early 2000s, health advocacy
companies began to appear to help patients deal with the complexities
of the healthcare system. The complexity of the healthcare system has
resulted in a variety of problems for the American public. A study found
that 62 percent of persons declaring bankruptcy in 2007 had unpaid
medical expenses of $1000 or more, and in 92% of these cases the medical debts exceeded $5000. Nearly 80 percent who filed for bankruptcy had health insurance. The Medicare and Medicaid programs were estimated to soon account for 50 percent of all national health spending. These factors and many others fueled interest in an overhaul of the
health care system in the United States. In 2010 President Obama signed
into law the Patient Protection and Affordable Care Act.
This Act includes an 'individual mandate' that every American must have
medical insurance (or pay a fine). Health policy experts such as David Cutler and Jonathan Gruber, as well as the American medical insurance lobby group America's Health Insurance Plans,
argued this provision was required in order to provide "guaranteed
issue" and a "community rating," which address unpopular features of
America's health insurance system such as premium weightings, exclusions
for pre-existing conditions, and the pre-screening of insurance
applicants. During 26–28 March, the Supreme Court heard arguments
regarding the validity of the Act. The Patient Protection and Affordable
Care Act was determined to be constitutional on 28 June 2012. The
Supreme Court determined that Congress had the authority to apply the
individual mandate within its taxing powers.
In the late 19th century, "accident insurance" began to be available, which operated much like modern disability insurance. This payment model continued until the start of the 20th century in
some jurisdictions (like California), where all laws regulating health
insurance actually referred to disability insurance.
Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts.
This firm, founded in 1850, offered insurance against injuries arising
from railroad and steamboat accidents. Sixty organizations were offering
accident insurance in the U.S. by 1866, but the industry consolidated
rapidly soon thereafter. While there were earlier experiments, the
origins of sickness coverage in the U.S. effectively date from 1890. The
first employer-sponsored group disability policy was issued in 1911.
Before the development of medical expense insurance, patients were expected to pay health care costs out of their own pockets, under what is known as the fee-for-service
business model. During the middle-to-late 20th century, traditional
disability insurance evolved into modern health insurance programs. One
major obstacle to this development was that early forms of comprehensive
health insurance were enjoined by courts for violating the traditional
ban on corporate practice of the professions by for-profit corporations. State legislatures had to intervene and expressly legalize health
insurance as an exception to that traditional rule. Today, most
comprehensive private health insurance programs cover the cost of
routine, preventive, and emergency health care procedures. They also
cover or partially cover the cost of certain prescription and over-the-counter drugs.
Insurance companies determine what drugs are covered based on price,
availability, and therapeutic equivalents. The list of drugs that an
insurance program agrees to cover is called a formulary. Additionally, some prescriptions drugs may require a prior authorization before an insurance program agrees to cover its cost.
The numbers of Americans lacking health insurance and the uninsured rate from 1987 to 2008
Hospital and medical expense policies were introduced during the
first half of the 20th century. During the 1920s, individual hospitals
began offering services to individuals on a pre-paid basis, eventually
leading to the development of Blue Cross organizations. The predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in 1929, through the 1930s and on during World War II.
The Employee Retirement Income Security Act
of 1974 (ERISA) regulated the operation of a health benefit plan if an
employer chooses to establish one, which is not required. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) gives an ex-employee the right to continue coverage under an employer-sponsored group health benefit plan.
Through the 1990s, managed care insurance schemes including health maintenance organizations (HMO), preferred provider organizations, or point of service plans grew from about 25% US employees with employer-sponsored coverage to the vast majority. With managed care, insurers use various techniques to address costs and
improve quality, including negotiation of prices ("in-network"
providers), utilization management, and requirements for quality assurance such as being accredited by accreditation schemes such as the Joint Commission and the American Accreditation Healthcare Commission.
Employers and employees may have some choice in the details of plans, including health savings accounts, deductible, and coinsurance. As of 2015, a trend has emerged for employers to offer high-deductible plans,
called consumer-driven healthcare plans which place more costs on
employees, while employees benefit by paying lower monthly premiums.
Additionally, having a high-deductible plan allows employees to open a
health savings account, which allows them to contribute pre-tax savings
towards future medical needs. Some employers will offer multiple plans
to their employees.
The private health insurance market, known in Russian as "voluntary health insurance" (Russian: добровольное медицинское страхование, ДМС) to distinguish it from state-sponsored Mandatory Medical Insurance, has experienced sustained levels of growth. It was introduced in October 1992.
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