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Universal Health Coverage: How Do We Get There? (Transcript)

Speakers: David de Ferranti, President, Results for Development, and William Hsiao, Professor of Economics, Harvard School of Public Health
Presider: Yanzhong Huang, Senior Fellow for Global Health, Council on Foreign Relations
January 9, 2012
Council on Foreign Relations


YANZHONG HUANG: Good afternoon and happy new year. Welcome to the Council on Foreign Relations. I'm Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations.

This is the first meeting of our universal health coverage roundtable series, generally (sic) funded by Rockefeller Foundation. I saw Robert Marten here. (Chuckles.) Yeah. The -- this series will explore opportunities, challenges, options, pathways of achieving universal health coverage.

And this first meeting, we are focused on how to launch and ultimately achieve universal health coverage. And we probably all know that global health -- the -- in the global health field, universal health coverage is building momentum globally. And so this is a very exciting time, probably since the postwar era with the rise of the welfare state and the spread of socialism. You know, now we have seen universal health coverage -- seems to be extending to additional 40 percent of the population worldwide if we talk about the efforts of promoting universal health coverage in U.S., in China, India and other countries.

So this is a very exciting moment. And we are also thrilled to see old friends and many new friends coming to this roundtable series. And you've probably noticed that my distinguished colleague Laurie Garrett also is participating, but she's going to participate -- join us by phone. And Laurie, by the way, is the co-director of this project.

We'll begin with brief remarks from Professor William Hsiao, followed by remarks from Dr. David de Ferranti. You probably all have the four bios. I just want to let you know that Bill is an international expert on health care finance. He is the K.T. Li Professor of Economics in the program in health care financing at Harvard, and he has decades of expertise in health care financing, experience in advising, assisting health system reforms in both developed and the developing world. I believe he is now serving as an adviser to the health system reform in China.

David is the president of the Results for Development Institute. And he is the former vice president at World Bank in charge for social sector sectors. He is also a senior fellow at the Brookings Institution and the United Nations Foundation and an adjunct professor at Georgetown University. So we are very fortunate to have two leading experts to speak at this roundtable.

And after both David and Bill's remarks, we'll open up the floor to questions and discussions. I just want to let you know that the meeting is on the record, so you can feel free to use and quote today's discussion. And please also turn off your cellphones.

And so we're going to start with Professor Hsiao. You have 15 minutes.

WILLIAM HSIAO: Thank you, Yanzhong.

Needless to say, it's a pleasure to be here. I see so many leading experts sitting in this roundtable, but I call it a square table. (Laughter.) And the question, I suppose, to answer is the $64 million question on the table for decades: How do you get to universal health care? And I don't pretend I have the magic wand. But I'm going to say some things to try to stimulate and provoke discussion.

I will start with a little bit of background so we have some kind of a common understanding such as what is universal health coverage or health -- universal health care. And that term was coined in 2005 at WHO, and then in 2010 that was again -- the report re-emphasized that and refined it. And I would say universal health care is a noble vision and based on equity principle. And -- but it's utopian for less developing countries. So we should look at it as a direction and a goal rather than something you can jump to it very quickly.

The "universal" means three things. In the latest report, 2010, by WHO, they gave a picture of a cube. Universal means covering everybody in the country. And the two, cover about every health service. And third universal is cover all the expenses. What they say really is reduce out-of-pocket payment. So that's the concept, universal, I want to leave with you so we can have more in-depth discussion.

In my view, that report has two new ideas perhaps we should focus on when we want to -- trying to move ahead. And one is that this report argues -- let's (not ?) call it financing -- the pre-payment, not insurance. Many countries had been misled, including China, by this word, "insurance." Insurance -- you only insure the big bills that can create serious financial hardship. And those incidences of these catastrophic expenses is low.

But in health care, first of all, we learned from the United States since the 1920s, people will not buy catastrophic health insurance. That's what was offered from 1921. In private health insurance, that's all they offered for decades, and very few people would buy it. What people would buy is pre-payment, for whatever psychological reasons is that they pre-pay for health services, and a portion of that is the large bills.

So I thought the report advanced our vocabulary and understanding a little bit better rather than misleading countries. I mentioned China was misled by that. When China introduced the so-called health insurance -- rural health insurance in 2003, China only insured hospital costs. Consequently, the demand shift to the hospital care away from prevention and primary care. So I thought WHO made that contribution in its 2010 report.

Second is WHO break a no-no. When I worked with Jeffrey Sachs back year 2000 and earlier, I argued to finance health care, you should worry about funding, new funds you can generate for health care. But another is improve the efficiency. My experience taught me in every country, including in the United States -- and now it's documented -- roughly 25 percent of our spending for health care, according to people like Mark McClellan and others, is waste. So if you can reduce that waste, that's a source of financing.

WHO's 2010 report highlighted that. I could not convince Jeffrey Sachs, when he led the Commission on Macroeconomics and Health, to really highlight that. He says let's just focus on getting more money into health. But really I do think there's a -- you can walk with two legs, both new funding and improve the efficiency.

And the WHO report gave this range, the 20 (percent) to 40 percent of the inefficiency in the health care delivery today. And I would say that's about right, from my observations in the field.

So then let's look at -- before we get into the specifics, I'd like to divide the countries into two groups for your discussion. One group is that these are the countries that have really been afflicted by HIV/AIDS and that really generate huge burden. And I don't think those countries can finance their own health care costs and they need donors to help them. Well, how many people does that involve among the developing nations? My estimation, that covers about 350 million people, a significant number but not the whole world.

Now, other countries, like India, China, Indonesia, Pakistan, Egypt, so forth, are not afflicted that much by HIV/AIDS. They make up actually 3 1/2 billion people. And they should be focusing not only on donor financing but how do they mobilize resources within their own country, because they have the capabilities to do it. So I would like to differentiate two -- the nations into two groups.

Now, then let's talk about financing for a few minutes. All of you are experts. You know there are a lot of effort made to develop innovations in health care financing, and David's group was active in that work. And suggestions about taxing airline tickets, financial transactions, sin tax, this I do not want to insult your intelligence by repeating those, other than just mentioning that's on the table for a long time.

I will suggest actually something that's not on the table for a long time but is in the academic world, and that is to say you really develop a new kind of social health insurance; new kind, not the German model. The German model is you develop social insurance for those who are in the formal sector, whom you can collect the premium easily through their employment. I would argue the new model of social insurance is that you do impose the social health insurance, you ask these formally employed people pay, but you use general revenue taxes (to) subsidize the premium for the poor people and near poor. That's also social health insurance.

Now, if you want to see how that works, look at Thailand, look at China, but that has not been made clear there's a new form of social health insurance, so people get confused by what you can do with social health insurance.

The way to improve efficiency, one is -- we already know the way, since Al Tamarter (ph) argued showing at that time what China had done, Cuba and other countries -- use minimally trained health workers to do prevention and primary care, and make the essential drugs available to everyone. That can reduce your infant mortality, maternal mortality drastically, and those countries find you can reduce infant mortality from close to 100 per thousand down to 40 -- 35, 40 -- just by these measures.

But then the question, why haven't we adopted it, why haven't we adopted these most efficient way to produce better health for the people? Here I like to draw a provocative statement, I think -- I call it American medical imperialism. I coined this term with my colleagues at Harvard, because we observed developing countries send their best doctors to United States and U.K. to learn medicine, they're held up as shining examples: Look what I can do. When they go back to their countries, they are the medical leaders.

American medical device companies and pharmaceutical companies actually support these fellows to come here and so forth. They become the role model. So consequently, countries' resources get pulled toward the high-expensive technology. And I would argue that this council can really do something about that, to break that, say the expensive high-technology is not an appropriate model for developing countries. You're at a different state of development; you should think about using different kind of technology, and we value that. They need legitimacy for that, and we have not given them that legitimacy. That's something we can do.

The other part I will say is we have not paid enough attention for governance. How do you really structure the governance of public hospitals and clinics to really improve their efficiency? I work in this field. I can tell you, we search literature after literature; there's very little written on it. That again is what the council and international community can contribute.

So let me just conclude, then. There are new ways to really improve this efficiency beyond what we already know, but one is trying to break this American medical imperialism. Second is really develop new knowledge on governance of public facilities.

Then I will conclude. Universal health care is not the end-all, be-all. And I think the council may have really a duty to have other seminars, that coverage does not equal to service. Universal, you can finance it, but money does need the transformation process to become actual services available to people. And that's a topic (which) has been neglected. You look at all the countries implement national health insurance, but actually most of the money turns out to increase the income of doctors and hospitals, do not benefit the people that much.

Best study was done by Paul Gertler in Philippines. He found for every $100 additional money pumped into health care, $60 went to the pockets of doctors, nurses and hospitals, profits. Only $40 really went for the benefit of people. We just completed a study in China, in my social experiment side, which involves 1.6 million people. We found the same thing. China is pumping tremendous amount of money into health care. Thirty percent actually benefited the people, 70 percent went toward supply-side profits and a better livelihood. We've become income-transfer program, I call.

So with that provocative thought, I turn this over to David.

HUANG: OK. (Chuckling.) Thank you, Bill, for that very provocative but stimulating remarks. (Laughter.)

So, David, you're going to explain how to get to achieving universal health coverage.

DAVID DE FERRANTI: Well, first it's great to -- it's a real privilege to be here with so many people who are working and thinking in this area and be on the podium with Bill. In fact, it's both terrific and terrible to be on the podium with Bill because Bill is so thoughtful, so much experience, and a lot of the points I would have liked to have covered he has already taken care of.

I'm going to -- in the spirit of opening a round-table discussion, going to try to, within my 15 minutes, cover three comments, four challenges and five concerns. So it's sort of like a menu at a good restaurant. And most of these will be framed as questions because I think that's what they are.

So among the three comments, the first is, there clearly is a huge upswing in action, activity, talk in countries globally, movement, some of which really is deep change, some of which is just the label of change on other things. There's a lot going on and more so now than in, say, half a decade ago and longer.

Now, will this current boom of interest and activity in the subject around the world lead to rushing into new policies and programs prematurely before the details are worked out or making bad choices? Will we see, in other words, some "ready, shoot, aim" where there should be "ready, aim, shoot"? And will high expectations be dashed a bit? And will disillusionment follow?

I'm hoping not, so I don't want to -- the fact that I'm starting with this question is not meant to signal that I'm a skeptic or something, but it's a very important question, I think, and a very important area for us to think about. And I remember -- I forget who said that it takes about 10 years to get it right in a major health financing reform and get it right and fully done, with some exceptions, but if you're not as well put together as some of the exceptions, it's a very long -- it can be a very long path.

My second comment, sort of coming from that first one, is, it might be good for us to keep in mind some of the roots of where this tremendous interest and activity in universal health coverage is coming from. And some of the ideas that get raised around that topic include the fact that incomes are rising. We've seen that growth in China, India, now Africa -- stunningly strong over a long enough period. So as it reaches to more households and rising middle class and others, there is the opportunity and the resources to take on additional questions, and universal health coverage is clearly among them.

Clearly also, communication channels being more developed, more active, people at all levels institutionally and individually in countries are hearing more about what their neighbors are doing within and across country borders.

There's also an idea which has even deeper roots, and that is, if you take hundreds of years of history and go back, there was a time when societies did not have things like collective action for fire or police or even justice or certainly education, schooling. And as incomes have risen and people satisfy their most basic needs for a meal, shelter, security, there does seem to be a pattern. Societies take on some of these collective -- or take on some of these matters collectively as people aspire to have more stability and protection in their lives.

And so the question before us is, is health now on that list? Does it come after -- is the 20th -- 21st century -- in some cases, already the 20th century -- taking on board? It certainly would appear so if you look at all the rich countries -- although here, in this country, there is still a lot of angst -- and not only the rich countries, but also going on down.

So there are a number of factors about the roots that should -- we should keep in mind, including some very interesting work which Arielle (ph), I think, spearheaded, which is that as economies rise and per capita income rise -- rises, there is evidence that people turn strongly to spending more on health. Now that spending can either be wise or unwise. It can be organized or disorganized. But there's -- there is some compelling evidence that as people get more wealthy and they satisfy their more basic needs or prior needs, they turn more to -- there's a lot more we could say on that, but I'll move right along.

My third comment is that it's not uncommon in discussions about universal health coverage to hear someone or hear the discussion evolve in a way that assumes that it's 90 percent about the technical design issues and 10 percent about the politics. But the reality, I think, is probably the opposite, that the real challenges are very political. And Bill was very thoughtful on that; maybe we'll have more time in the discussion to follow.

So those are my three comments to start with.

Coming to the challenges, it's clear that the differences in context that countries face, not only geographies but also points in time, are hugely important, these contextual differences. And they really require very careful consideration of experience and adaptation of ideas and creation of new ideas rather than simply importing specific models from one country to another. And those who have ignored that and just said, well, give me the answer as it's been cooked at some other place, do so at their peril.

So that's a challenge for leaders, is to navigate their way between using international experience thoughtfully or keeping that in front of them while also saying, well, how much locally is critical for how we design our systems? And I think many of us here would say it -- a lot is critical, from the context.

Second, the countries that are now grappling with these issues often have very large informal sector populations. And this obviously, as I think Bill has already foreshadowed, raises massively different questions from countries where the informal sector is much smaller, and making it more complex for governments at various levels to figure out how to pay for health care, collect -- whatever payment systems they want to put in place and so on. So there is a risk that experience from countries that have not had to solve the deep problems associated with large informal sectors are brought into countries that do have large informal sectors -- that inadequate attention is paid to that complication.

My third challenge is managerial and administrative capacity and where it's limited. These are complex issues -- how to design, how to pay for, how to organize services. And I think we've seen many examples around the world where countries have set out -- and I would put Ghana, for example, in this -- on a -- on an ambitious path, and getting the implementation to make it possible, getting the things -- like if there are cards, insurance cards or whatever they're called, to get out, getting them out, keeping them current; if there are claims to come in, that can be a massive nightmare; and so many other related issues.

My fourth challenge is about fiscal space and is there room to pay for whatever countries are going to undertake? So leaders have to grapple with that.

At a meeting -- I guess it was last year -- of six countries, where there was some sharing of experience, the question came up, do you see a way to pay for sustainably over the long term the system that you're now aiming for or indeed have in place? And all six said no. I'm not going to mention their names, because we're on the record here, (so I'll get ?) -- all six said: No, we don't.

And as we talked about it further, these designers and runners of these reforming health systems were basically arguing, if you build it, the money will come. If you build it, patients, households, who are also voters, are not going to let it be taken away.

So that raises all kinds of issues, and our macroeconomic colleagues squirm very, very uncomfortably around that kind of tendency towards an unfunded liability.

And my 4.1 challenge, since I have four challenges, I think, is that -- is again just to underscore that the domestic political agenda, which translates into political challenges, political economy questions -- who's going to win, who's going to lose, and who's most vocal, as distinct from most vulnerable -- can certainly have a major impact on what comes out.

There's a very interesting case study that Ricardo Bitran has done about Chile's experience. And when you read it, you come away thinking, you know, gee, the issues around who was in what position at what moment in time and who could do what had enormous impact on choices and some of which were initially bad choices that then took a long time to get right.

And finally, my -- the five concerns or -- I say "concerns," but they're really more question marks, I think. Will we see more countries moving towards demand-side financing, where payments follow the patients in some way, or will we see a tendency towards really recooking of essentially supply-side financing? And that's a -- that's something that I and, I think, we should be curious about, not necessarily prescriptive about, but in a position to interpret experience, so that as future policymakers ask which way to go, there's something we can -- we can say to them.

The second of these concerns or questions is, will the tax-based options for revenue generation emerge as the predominant financing? We -- as Bill referring to, we've seen models in -- historically, the German model and others, relying more on payroll taxes. But as countries in Africa and Asia move out their own systems and grapple with the difficulties of a payroll tax system in their particular context, are we going to see that there are different kinds of models, so that our old taxonomies of Bismarck and Beveridge and so on fade away or get overtaken by different approaches? And I think Adam Wagstaff is making that argument now, and others.

My third concern -- question is, how will countries choose to go in the sequencing of how they reach the poor? We've seen models in the past of countries that seek from the outset to reach everyone, sometimes with the explicit understanding or thought that if they did not reach out to everybody in -- at the beginning, they wouldn't be able politically to construct a coalition to support the whole program. And I think many Latin American countries have been through that debate.

We've also seen some cases where there were special approaches for special sub-populations, leaving huge legacies of conflicting and separate systems that then become very difficult to rationalize or integrate, leaving big questions about fairness and equity.

And my fourth and penultimate challenge or -- sorry -- concern is about the impact of these reforms. What would we in fact see? Will we see success in improving financial protection and improving access? Those would be the things we would most expect. And we have some encouraging evidence that that will be the case. Will the poor actually be included or left behind? I think we'll need to go and carefully evaluate some of the systems.

I'm almost done.

And what about that question about health impact? We'll have health outcomes -- there's a lot of doubt, and a lot of attempts to find that health impact come up empty. So I think we should give serious thought to the fact that this is not about major changes in health impact.

There is a new study that Peter Smith at Imperial College and Rodrigo Serra-Moreno (sic; Moreno-Serra), a colleague of his, have recently put out that argues that yes, they do find health impact. And they're using some interesting econometrics to try and bring that out. But I think that the jury is still out.

And final question is really, since we're -- as the council concerns itself with the U.S. as well as international development, is there intersection, even interaction, between discussion about universal health coverage in developing countries and the U.S. debate? Arguably, there's more confusion generated than clarity when these two separate debates get put together.

So I hope that's provoked some interesting topics for discussion.

HUANG: Thank you, David. This is very interesting indeed.

So I'm going to be the first -- (chuckles) -- use my privilege to ask the first question. When I'm actually comparing these different countries have claimed to have achieved universal health coverage or attempting to achieve universal health coverage, I found some very interesting statistics.

For example, in Brazil in 2007, 58 percent of the population -- actually -- I'm sorry. The out-of-pocket payment -- the share of out-of-pocket payment is nearly 58 percent, OK, even though Brazil claimed they have achieved universal health coverage.

In the meantime, when I look at China, right, at that time -- it hasn't -- hadn't even launched the universal health care program -- the out-of-pocket payment share was only 53 percent.

And in Mexico too, I found that actually the out-of-pocket payment share is higher than China, which is 54 percent in Mexico. You know, it claimed it is on the road to achieving universal health coverage.

So I was wondering: What is the common denominator here? When can we say a country has indeed achieved universal health coverage? Because I thought Bill already talk (sic) about, you know, what do we mean by UHC? And so we have sort of a consensus of what it means, and also we might have a consensus on how should it be done, but you know, my question's how it should be evaluated. Do we have a consensus on that?

HSIAO: Well, I'd be happy to share with you my experience with few countries.

For developing countries, when they're trying to achieve UHC, the debate is, do I try to cover everyone first -- with limited resources, do I try to cover everyone first, or try to cover a group of people in depth but leave other people out? In other words, bring groups in, step by step, but start with a rich benefit package with very little out-of-pocket payment.

At least I haven't -- never seen any published paper, but my experience is that countries find if -- they need to establish the infrastructure to enroll everyone. And if you can do that first, then you build out the foundation.

Now, as your economy and the revenue grow, you can then expand that benefit. And if you want to see a country that did that -- doing that right now -- it's China. China only -- China right now has covered close to 94 percent of the people and -- but it's shallow coverage. And China now is moving already, step by step, trying to deepen that coverage; which means more services as well as reduced out-of-pocket costs.

And you can -- you can argue with -- maybe some other alternative strategy's better. But then, I have not seen any theory or country really show that's a better experience. If you look at a Latin American country, that's following the German model. They cover the formal sector workers -- including Mexico. Actually, they do not want to expand, because they got what they want and they do not want coverage -- pay taxes or fees to cover others.

Same thing with Thailand. Thailand built up a strong insurance system for the civil servants and the formal sector employees that cover only 25 percent. They're the ones who resisted the prime minister to expand covering everyone. And when they did it, they covered only, really, with much shallow insurance. So Thailand right now has a three-tier insurance program, basically.

HUANG: David, do you want to --

DE FERRANTI: So picking up on the part of your comment, it was: How do you know when you're there?

HSIAO: Right. That's it.

DE FERRANTI: How do you know and, therefore, how do you measure? I think -- I think we've got some -- a variety of perspectives on that, including the ones Bill just said, which I think are important. We've also heard Chris Murray say, in his definition of effective coverage, it's when the proportion of the population that receives effective services out of the target population that needs those services is a hundred percent. We've got the WHO official definition: access to key promotive, preventive, curative, rehabilitative health intervention for all at an affordable cost.

But I guess what I sometimes think about is that this is really something that countries determine for themselves. They have different objectives which, as Bill has pointed out, can include patient satisfaction, financial protection, access to services, quality. And at some point -- you're never -- you're never going to get, I think, to a hundred percent so that no one ever has any problem that's uncovered -- question how close you get becomes what a particular society, given its objectives.

Now, that's not a very -- that's not -- you can't then sit in Geneva or New York or Washington and do a chart that says, "You made it; you didn't." But I think it underscores how important it is to recognize that countries -- and Uwe Reinhardt does this a lot, and he says that you can have different systems depending on which -- what your social objectives are, what your country's objectives are.

HUANG: Thank you, David.

I think Laurie has a question to ask.

Laurie, are you there?

MS. : Let me go check on that.

HUANG: Oh, we can check. But we are going to -- oh, before, actually, we have Laurie to ask, we are going to open the floor up to questions. Please identify yourself and your affiliation before responding. And please also flip your -- (inaudible) -- card so we can see you, to indicate that you have a question.

MR. : There's Chris.

HUANG: Oh, Chris.

QUESTIONER: Chris Decker (ph), from the NIK (ph). Thank you very much for the presentations and the discussion today. I had a question very much on the politics of it, as you were just mentioning for Latin America and other countries where the status quo and getting over the status quo -- in Thailand, in particular, you had a military coup, and when they installed civilian leadership, within three days of naming the cabinet minister for health, he announced (ordering ?) a universal health program, without any political consideration.

So I ask -- my question is the politics of it. Does it actually -- what are the requirements, and where do you see action being possible, getting over this, the status quo? And what type of dynamics are necessary to change the considerations? (Laughter.)

HSIAO: Do you have any harder question? (Laughter.)

I wish I know the answer, but I can -- I think if you study the literature, this is called historical institutionalism. One group of people -- writers, researchers -- say the -- there is space opened up when there -- (assumes ?) democracy, when a country being democratized. Then people -- the voters, the common people -- demand health care and education and food, and that's when the leader responded. And your example of Thailand, that's what the prime minister sanctioned -- campaigned on. And so when he came to office, he right away implemented that.

And however, then, that doesn't apply to China, but then I like to compare with China is this. China had two events came together which prompted government to take on health care. One is, there began to be public protests. Even in the authoritarian state, there are a number of people in the villages and cities protest they cannot get access to basic health care. And that information is actually transmitted to politburo members.

Then what triggered it for them to go over that threshold -- over threshold -- is SARS, when they realized if they did not deal with their health care problem, this could create a big social and economic and international problem for China. So that's what prompt China to deal with that. And if you look at India, I will get -- I will say that democracy has a great deal with it, what drives India to try to develop a reform, and -- but in African countries, that differs.

So my conclusion is, really, it depends on the political system, but the fundamental common denominator seems to be there is some unrest among the people that actually made the political leaders pay attention. And that same thing with the developed -- even a higher-income country like Taiwan. Taiwan was moving toward democracy, and the opposition start taking on national health insurance as a(n) issue. And so -- and I'm sure David can speak a lot more; he's a(n) expert on Latin American countries.

And then if you -- let me just add, if you look at Ghana, Ghana introduced universal health insurance because the opposition -- there was discontent. The opposition party seized that issue as a campaign issue. And then they passed it. So -- David.

DE FERRANTI: So I had written down three things -- and this sounds very consistent with what Bill has said -- that you need. One is a sense of crisis or a need for -- something has to change significantly. Protests in the street, it can be expression in that. Voter turnout and what they say, using their votes radically different from the past, can be another way.

Second, leadership that has adequate authorization, from whoever its authorizing environment is, to be able to act and to take difficult choices. So if it's a democratic system, a leader who's elected with 51 percent in a swing election is not going to be that authorized leader; but a landslide that's accompanied with a sense of need for change that enables the leadership to have in its parliament the ability to get things done.

And then thirdly, that leadership senses some need to demonstrate that they're taking action on the problem. So you're going to -- you've had some strong leaders who got all the power, and there's a sense of crisis, but if they don't feel that they, for their own survival, need to change, then they may not carry through.

HUANG: See if I get both of you right: that both democracies and authoritarian states can generate incentives to create -- launch universal health coverage programs.

DE FERRANTI: And both can fail too.

HUANG: Both can fail. (Laughs.) Exactly.

I think the phone line works now. Laurie, are you there?

LAURIE GARRETT: I am here. Can you hear me?

HUANG: Yes, I can. If you -- be a little bit louder. (Chuckles.)

MS. GARRETT: OK, I'll pseudo-shout.

I -- first of all, this has just been a fantastic conversation, and kudos to everybody. I'm -- I think we're really getting some fascinating ideas here.

Key thing: You know, David talked about, basically, asking is universal health coverage a sort of 21st-century version of public goods expectation on the part of the rising middle class around the world? And then there was the question, well, just because you have health coverage, doesn't mean that you have access to meaningful services. So what I wanted to ask both of you is, to what degree do the metrics we put in place to measure whether or not a system is working, failing, meeting expectations, not meeting, end up driving the very nature of what system you end up putting in place that you call universal health coverage?

And just as an example, you raised the point that, in many cases, most of the money goes to increased salaries. But if increasing salaries decreases inherent corruption within the medical system -- so that doctors no longer require payments in order to use sterile syringes, for example -- is that necessarily a bad thing, that so much of the money skews to health workers? Again, it's: What are we measuring? What are we trying to demonstrate are the outcomes we're seeking to achieve? And do they mesh with what the rising middle class expects from a universal health system?

HUANG: Bill?

HSIAO: I give you a slightly longer answer. I think what people values is the access -- the ease of access, and then they got satisfaction from the treatment. But that really differs from the societal goals. Societal goals is you want to measure the improvement in health status of the population and you want to see how much -- how many people are prevented from being impoverished by health expenditures.

And to me, that often is the problem in the countries I work in -- worked in. You can convince the political leaders the social purposes; that is, you can improve the health of the people, and that will help to improve the economic development -- that is, people are more healthy to work, to learn, and so on and so forth. But that's not -- at the individual level, the measurement is: Do I have good access? But good access actually does not necessarily mean better health outcome.

So I don't know the right answer, but I think you have to measure all of -- all of that, both -- both the social benefits and also what individuals value.

The -- your point about -- I like to say the studies I cited in China, Philippines -- actually, in both cases, the money went to the higher income of hospitals and doctors. That did not reduce, necessarily, under-the-table payments or kickbacks. These are really additional income to the -- in other word, the payment -- if I can say -- again say a provocative statement, I don't think there's a limit to human greed. (Laughter.) And so if you think, oh, doctors and hospitals are going to be satisfied -- just OK, I only have a target income -- and then they're happy with it, I think that needs a -- need a little bit more proof, Laurie. (Laughter.)

HUANG: OK. Greedy doctors. (Laughs, laughter.)

MS. GARRETT: Point taken. (Laughter.)

DE FERRANTI: The -- on the point about do the metrics drive the result, the outcome or how things develop: I'm sure they do, but I would add that the politics drive the result even more. What the designers and we say about -- and what we measure, is one thing. And what people with their votes and their -- and their money and their decisions, is another. And the devil is in the details, in getting these programs right. If you get it wrong, that will drive through -- people's opinions will drive through to the result. So I would -- that's what I would add.

On your point also, Laurie, about the example you happened to choose, which is, you know, if more dollars -- more money gets to health workers through corruption, is that necessarily a bad thing: I think that's a good point. It -- but just as the road to hell is paved with good intentions, I think the road to heaven is -- can be paved with bad intentions. You don't want -- you can't predict these things in advance. So it's very hard, I think, to measure how societies will want to go.

HUANG: OK, well, thank you, David.

Our next question is from Professor Denton.

QUESTIONER: Thank you. We've been touching on many different changes that are going on, and in particular you have mentioned the rising middle class. But this is also going to have a huge impact on the type of health care that's being demanded.

What I'm thinking of specifically is, with the decline in fertility, you're seeing an impact on women and on children, their health care needs, but you're also seeing a change in the age structure, with a lot more increasingly older people. So this is going to have a feedback loop on the demand for health services that is going to be generated. I just wanted to throw that on the table as we go forward.

HUANG: Will you talk about it? (Chuckles.) You -- (inaudible) --

DE FERRANTI: Hazel, I think that's, you know, a terrific point. I agree; I think we're seeing that. I think the extent that countries don't plan on that, they invite trouble. And I think the aging factor is going to be absolutely huge, because I -- maybe I can take a corollary from -- Hsiao's proposition, we'll call it, which is that humanity knows no limit to greed: I think any of us as individuals know no limit to how much health care we want when our own lives are on the line.

HUANG: Bill, you --

HSIAO: I think you bring up a(n) excellent point, but let me just offer my two cents' worth. A society has to set priorities. And today we have a common word used, we throw around; that is, we cover basic health care. But what is this basic? Really this is -- and to which group of people? And I think -- so therefore, the -- in terms setting priorities, where do you get the -- where do you have the biggest problem? Who are you trying to satisfy and -- this is the difficult policy-making, this process.

HUANG: Doctor Iling (ph).

QUESTIONER: Thanks very much. This really was fantastic, and I must compliment both of you. And I'll -- will always remember your -- what -- there's no limit to human greed; is that right? (Laughter.) I don't know about you, speaking about doctors, I mean -- (laughter) --

HUANG: You're the exception. (Laughter.)

QUESTIONER: But a couple of things. One, when you spoke about it, I was intrigued by your definition about what is this universal health care, and why do you need it. And you pointed out that -- (inaudible) -- would say there's always been universal health care, but the -- a very small portion is formal, and a large portion is informal. And what doctors have tried to do is to make more of it formal and less of it informal. But there's always been some, as your colleague has always said.

But David, you mentioned the idea of key interventions. And you made the point, Bill, that what are these key interventions? It depends very much on the problems with which you have to deal. And since I've always been of the view that health care is a bottomless pit -- no country will ever or can ever satisfy all the health care needs of its people -- if that is true, are you prepared to enter the concept of rationing from the beginning in your discussion of health care? Let us begin by saying that there will be some rationing. Most of the discussion assumes no, there is some utopia; whatever you want to be covered will be covered. Are you prepared to say yes, from the beginning, there will be rationing, it's just what kind of rationing and to whom will be rationed?

HSIAO: I volunteer to answer your question. As an economist, I believe rationing is necessary because the medical technology has moved to such level, no nation can afford it, as you said. And I don't mind telling you Saudi Arabia, Kuwait, United Arab Emirates invite me in because I thought those nations would be -- can afford it. But they invite me and say, I can't afford it. Now, tell me, how do I deal with this problem?

So rationing is a word that's said in different ways privately, but never said publicly. (Laughter.) And so that's -- unfortunately, it's a dismal condition of human existence for health care. And -- but the question is how do you ration. You see, economists have fooled the world again, I think, about this. We do not call price -- charging people by price "rationing." But price is the most common way of rationing. So the United States is rationing health care, but as soon as you say, let's try to use cost-effectiveness to decide on which technology we'll adopt, then we say, oh, rationing, death panel. (Laughter.) One thing the economists and the writers can really -- to articulate is telling the world price is a rationing mechanism instead of how you want to ration, where there are other alternatives.

I teach a course -- I list -- one class is -- I discuss about eight ways to ration, including in most developing countries. Do you have a choice of your doctor? That's a rationing mechanism. What's more important to a patient when I go to a clinic or a hospital, whether I can choose a doctor whom I trust and have confidence in? Well, Hong Kong, the rich territory of China, will not give people that choice. And -- but meanwhile they say that's not rationing. So if we are much really focused on and able to talk more different ways of rationing and what's the consequences of it, I think we will also advance the field.

DE FERRANTI: So to your -- the point in your question, George, about whether we can look forward to a time when rationing will be discussed more explicitly up front, I guess my thought is that certainly is rational, but I don't think it's going to happen. (Laughter.) And you know, I think Henrik Ibsen was right that you must never take away the illusions from people, or they won't be able to live. But it wasn't people, it was systems and countries and so on. I think the first political party that explicitly talks about how we're going to ration health care is going to lose. So I'm not defending it, but I'd -- just sort of being a realist about it.

I think in the same sense, George, you said universal health care, in some sense, has always been there. It's been either formal or informal, and we're just talking about shifting. In that sense, rationing has always been there and always will be there. Bill is making that point. There are dimensions of it we don't spend as much time on as we should, including the rationing of information. And I think it's very interesting in this country, where you -- if you've got the money, you can -- you can buy lots of things, but you can't always buy that information. And some of the wealthiest, highest-end health providers in hospitals around the country don't necessarily follow the same practices, and that information is very hard for individuals to get out even with all the money in the world.

On your other point about the key -- who are those key services, I was quoting the WHO definition. And you -- since you come from PAHO, then you must know the answer. (Laughter.)

QUESTIONER: But not in a publicly -- (laughter) --

HUANG: This is off the record. (Laughter.)

Our next question is from Dr. Data (sp).

QUESTIONER: Yeah, what we are listening -- and the definitions from the different -- the world bodies of universal health care -- if you see from governance point of view, it seems to be a more often -- I represent a government -- it's a more often top-down approach, the way the government wants to govern. So as a result, two things happen. The same -- the universal model -- you've got to find -- like, you know, try to fit the socks in every feet, which is not true.

And the -- secondly, in order to govern that, we only focus on the health sector. As it goes more towards the developing countries' context, really at the local level, you cannot see that the health sector you can differentiate from the livelihood context. And it's true for any level of the -- you know, the economy. Only the high -- the developed economies -- even the middle class within developing economy can support or can afford or access that medical -- the health care system because of the higher income. But in the -- as we go at the lower level, we cannot -- if you want to have universal health insurance (at the cover ?), we cannot differentiate it with the livelihood.

And provided since we do it -- like one example, last week there was a conference where Amartya Sen, the Nobel laureate -- like, she was giving a lecture on poverty and cancer -- cancer coverage. There is a -- there was an example -- there was WHO project in one of the villages in India. A lady was detected with a uterine cancer. And she couldn't be brought to the treatment before six months. What was the result? She said that who will -- who will cut the paddy; who will supply the rice to my husband? So that prevented -- so if you see the health care or the insurance, at that level, it's putting the same type of -- you know, the solutions, as Dr. Hsiao has said -- like, as we try to give the same prescriptions in the age of global -- you know, the global economy, as well as the imperialism also comes along with that. So we have solutions to the other people.

So I think we have think in that solutions also the bottom-up solutions which can give this. It's -- everything is a top-down.

HUANG: So it's a social determinants of health question?

QUESTIONER: Yes. (Laughter.)

MR. : Yeah, go ahead.

HUANG: OK, I'll take this as a comment -- (laughter) -- very constructive one.

Next is the -- Dr. Bump.

QUESTIONER: Yes, thank you. I'm Jesse Bump, Georgetown University. I just wanted to contribute to the discussion by sharing some of my research results. Mr. Decker (sp) asked when do countries make this transition. And I think we just heard again about that.

I did a historical analysis, also generously supported by the Rockefeller Foundation, and found there were four factors common to when countries make the universal health coverage transition. One is a social contract renegotiation moment, usually some kind of crisis. SARS, as Professor Hsiao said, provided that moment in China. Two is the economic resources, often a period of economic expansion.

Three, there has to be existing infrastructure and delivery capacity. In the Beveridge model we heard about before, that was constructed during the Second World War, for instance, the hospital capacity.

And number four is popular demand and solidarity. So the population has to want it and be willing to cross-subsidize at some level, and I think that's the governmental aspect we were hearing about.

So those are -- were my findings, and I would like to ask our panel if they see universal health coverage as anything different from what health systems have been trying to do since the beginning; that is, if it's an aspiration to do the most or more with what they have. Is universal coverage something new or is it something we've worked toward for a long time?

HUANG (?): I actually also have a follow-up question, because while we're talking about universal health coverage, it is also a movement I would call health systems strengthening. Are those two the same things?

DE FERRANTI: Shall we go first and then -- (laughter).

QUESTIONER: Good question.

DE FERRANTI: Well, it's a good question. And I guess I have two parts to mention. The first part, when you were talking about health system strengthening, to use that term, of course that's not -- that means many things in many contexts and many problems. And so I would agree with you that universal health coverage is in some sense tackling the same issues and often in the same way, but since the first isn't monolithically the same in every situation, nor is the second.

But I think the more important comment I wanted to add is a more tactical, and that is that -- how many conversations have we been in when we're trying to convince someone or some group, let's go forward together on health-system strengthening, and that institution or person falls asleep? Health-system strengthening is not a tactically very attractive banner to raise, whereas universal health coverage clearly is.

HSIAO: I would just add -- you are a historian, Jesse, I know that, so correct me if I'm wrong. Historically, I don't think that countries were pushed for universal health coverage. And to me as a lay, non-historian, I observe this is being accelerated, my hypothesis is, because this is an idea that's being promoted by international organizations, as well as the argument like Marty (ph) is saying about the equity.

But if you -- my reading of the histories in earlier years, decades or centuries, this universal coverage is not on the agenda. It's a very gradual, (steady ?) expansion along with the social-economic development of a country. But now UHC is applying to mostly for low-income countries and asking what resources can be brought to bear, including from donors. Those issues was not on the table before. So I think that's somewhat new.

HUANG: (Inaudible.)

QUESTIONER: Thank you very much -- (inaudible). I do have a question, which might be technical, but also some general comments. (USAID ?), of course, cares a lot for strengthening health systems, and I personally agree that universal coverage is a sort of a "true north" concept which allows to align the many concepts of systems to deliver access for all to appropriate health services at an affordable cost.

And I also believe we are in the middle of this panel personally, as you know, in which universal health coverage -- the outlook of universal coverage in the developing world has been moving from laudable but unrealistic to feasible and perhaps unavoidable in those countries that are moving up the economic ladder. And there are many factors that would allow for this wholesale moment as opposed to the occasional episodes in history in the last hundred years. And I believe, of course, among those is human rights and economic development.

Ten years ago Jeff Sachs said that you need about $34 per capita to provide some of the basic services. If you bring that to today's dollars, that will be about 50 bucks. And he, of course -- maybe he did help to bring more attention and resources to global health, but he did miss this -- what we are witnessing now, this economic transition of health and these opportunities on domestic finance and reorganization.

Nigeria, for example: Just from 2009 to 2012, just in three years, the growth per capita of Nigeria -- just the growth, not the total GDP, but the growth of the last three years -- is 10 times the $50 you need to provide the basic health services to each Nigerian citizen. So just the form of the growth of the last three years in Nigeria should allow 10 times possibilities to cover the basic service of Nigeria.

So the possibilities exist now that 10 years we couldn't imagine. And this is happening in Uzbekistan, it is happening in India, it's happening in many countries, where the growth afford things that we can only imagine 10, 20 years ago.

How it gets done, of course, is paramount. And on the one hand, it may be that it is the -- the supply of American medicine -- (inaudible) --, but I believe, like with David, that there's a universal demand for wellness and for health -- first saving lives, later more wellness -- and that that demand will get manifested. If the governments do not orchestrate this demand as economics allow it to grow, then the private provision will explode in an unregulated fashion by default, not by some evil force.

And so as happened in China, even the government was growing, it was not growing as fast as its own economic growth called for. And now, of course, we are trying to do something about it.

I also think, David, that the money will come, whether or not you build it. And building the system will make sure the money gets used in a more efficient and more equitable way. So since it's coming -- that's a different way to put it -- since it's coming, we need to be ready for it.

And then my final point is -- and the question, then, Bill -- is out-of-pocket. Of the three dimensions (of the cube ?) -- because measurement is, of course, very hard and the out-of-pocket expenditure is the one thing we can (cling ?) a bit better -- in effective ways as opposed to nominal aspirations of (corroboration ?), death and -- is whether the out-of-pocket variable itself adjusted for levels of income -- because, of course, sometimes just the rich spend it all doesn't mean a lot, but whether that alone might be the one variable that would be highly correlated, because of the demand, with whether you have the right coverage and the right depth of the coverage at (a negative point ?) in a society.

So whether out-of-pocket could be for us a technical variable to measure coverage in a simpler way, what is your sense of that?

HSIAO: I think the out-of-pocket payment is a good measure, but that's tied to the services you want to cover. So, you know, let's say if you don't cover dental or eye care, which is part of so-called health expenditures, then you could be getting a very high out-of-pocket cost. So I think it needs to be done carefully; what are the basic services you want to cover or how much of that is coming out from out-of-pocket, and that that would be a good measurement how effective is your system, both because that tells you how much really your program is benefiting the people.

QUESTIONER: To further that, then, I guess we don't assume that you go to zero out-of-pocket but that you can move from 60 -- 50 percent in Africa or nearly 80 percent in India down to maybe 20, 30 percent, leaving room still to use the money to guide behavior towards the most cost-effective basic interventions and away from the more expensive ones. But again, that measure, in a way, should be an aggregate measure of the demand for either the benefits package or the depth of those benefits packages. I just wonder whether there's any technical -- just correlate or work between extent and depth of coverage and the aggregate out-of-pocket adjustments for income levels.

HSIAO (?): There's no normative answer to your question, but most of the studies trying to look at out-of-pocket costs by income level because you can -- logically you will say the poor people can't really afford very much, but as you point out, rich people may be able to afford more. But in terms of what's appropriate level, I think that's hotly debated.

Economists was -- want to minimize the moral hazard and argue for higher out-of-pocket costs. And for equity reasons, you want to, like Canada, make a law absolutely for physician and hospital care is zero and, if anybody charge patients for hospital or physician services, then that person cannot receive any reimbursement under the Canadian National Health Insurance. And -- but it's restricted to hospital and physician services.

HUANG (?): Thank you.

MS.: Thank you.

HUANG: David?

DE FERRANTI: Just two quick things to add. I agree with Yerielle (ph), whether you build it or not, the money will come; but as we know, how it comes and whether it's well used and goes to the right places is very much in play.

And secondly, I think it's -- you're right and it's appropriate that out-of-pocket should be an important consideration because to run -- to go back again to the -- sort of the big, almost philosophical question of the extent to which health and people's desire to have health (covered ?) sort of collectively is part of a deep process.

Transition from a society where everything is 100 percent out of pocket means that that health care system is being paid for by the sick or those who need health care, who are, from some equity standpoint, not necessarily those best able to bear, on their shoulders alone, the entire cost of that health system -- so that's a thousand years ago where you -- everybody's on their own -- to a system where it's much more shared, that means that there is that shifting -- equitably shifting towards those who are not necessarily at the worst, most vulnerable moment for paying their share. So I think it's important to keep that variable before the discussion.

HUANG (?): OK.


QUESTIONER: Thanks. I'm Dan Altman, representing Dalberg Global Development Advisors.

We spoke about the two major goals of universal health coverage at a societal level being reduction of financial hardship and better health outcomes. But I think we really mean better health outcomes for the buck, right? I mean, if I put enough money in, I can get whatever I want, right?

In this country and in other countries, when we've discussed universal health coverage, we've talked about getting better bang for the buck through better coordination of care, economies of scale in administrative costs, less inappropriate use of care, like in emergency services, things like that. They're -- there are maybe seven or eight different channels through which you might get this.

Now, David, I believe, said that we don't have a lot of good measurements of impact, and maybe it's too early in some of these countries to get good measurements of health impact. But can we start to create that evidence base for these efficiencies that you're actually getting at least the same health outcomes for the buck? And I -- because I feel like if you disaggregate them into these seven or eight categories, you can do very focused studies of these things. Do you feel that the evidence base is better there?

DE FERRANTI: I do. It still needs a lot more work, but I -- that's a very good point actually, and I think taking -- continuing to look at that is a -- is a good idea. The impact is harder -- the health outcome impact is harder.

HUANG: We have -- still have two questions.

Tom (sp) and Robert (sp), maybe we're going to collect the both of them, the questions to (him ?).

MR. : No -- (off mic) --

HUANG: Oh, there's -- I'm sorry. (Chuckles.)

MR.: Jim.

HUANG: Jim, yes. The third question?


QUESTIONER: The 800 pound gorilla in this room is the American lack of a system. And we've been through the politics of some kind of health care over our lifetimes starting with Truman. But we saw an election in 2010 in which people were defeated because they supported what was on the table.

And it always makes me nervous, talking about politics when our esteemed experts and my good friend Bill -- I -- we used to be neighbors at Harvard -- when you use the word "rational" or "rational situations," it makes me very nervous because that's not what determines political outcomes.

But, you know, do you -- either of you or any of us foresee a way to take on the political fears and the political hatreds that are generated by this debate? Because as I live in this society and see people getting bigger and bigger -- (chuckles, laughter) -- and that just means they're going to die earlier, I question the -- what's taking place. So my question is the politics of health care.

MR. : OK.

HUANG: OK, Jim (sp), the mic --

QUESTIONER: Yeah, just kind of a point and a question.

First on the point, I -- I'm a little concerned that we conflate the issues of health care (covering ?) with health care outcomes. So people don't actually get -- go to the street because their health outcomes are low; they actually go to the street because they have a sense of injustice around their health access.

And I think therein is the conundrum because we're -- we measure health care coverage based on what flows through an organized system of health care workers, whereas we measure health outcomes from processes that largely relate to things outside the health sector instead of inside the health sector, which is why I'm a little concerned about Bill's point that -- about the 70-30 split in the Philippines and China.

Well, of course, you know, that's where you're moving the money; that's where you're going to see the increases, which brings me to my question and a -- I think, a defense of George's (sp) subtle point that it's not just about the health provider and hospital greed, but there may be some other issues here that we're looking in the human dynamic, in that our search for the fountain of youth, that the vast majority of health consumption around the world -- and that's a $6 trillion consumption -- is in people who are 65 years of age. And even economists would appreciate that the -- a diminishing return for every dollar that is invested after 70 increasingly up the -- with time.

And so we are -- we're constructing a huge, you know, health inequity with respect to younger people and children in particular. And at the same time, we're doing so in only -- you know, facing what is a hugely increasing demand, which is increased further with democratization. So we have positive forces of democratization, we have longevity, and we have a demand for health consumption which is disproportionately in the senior years, which, of course I thought was, you know, illogical earlier. But with each -- with each passing year, I actually see the value in that. (Laughter.) But how is it that we are actually going to pretend to have a discussion of universal health care until we can actually tease out the discussion about how do we actually -- as societies are we prepared to maximize health outcomes? Because those aren't the same thing.

HUANG: Robert (sp)?

QUESTIONER: Thank you, and thank you to the speakers and to all the guests. I think this has been a really great discussion.

My question is looking towards the future -- and I think in 2015, the Millennium Development Goals will be coming to an end -- and so I just wanted to ask the panel if they think there's any possibility of the universal health coverage agenda coming into play for the post-MDG discussions? And then bracket that, and then say, actually, is that even the right question? Do the post -- do the MDGs matter and is the post-MDG discussion worth having?

HUANG: Well --

MR. : Sure.

HUANG: David, do you want to go first this time?

DE FERRANTI: Well, on the -- I thought -- I think terrific question about the politics and as they apply to the U.S., I wish I had the answer. You may.

I think the book that's been most helpful for me in thinking about it is the book "Deer Hunting With Jesus." (I don't know ?) whether it's well known here. It's a book but it's by a journalist, and worth finding, in which he -- you know, I think that if there's change, it's going to have to come from not the most intellectual, but from people putting together how they're going to vote. And the messengers that they listen to are as -- are going to be critical in getting the messages across.

And this particular book I think is fairly thoughtful about that and -- journalist returning to his roots in a very working-class town, and asking: Why is it that these voters are voting for candidates that are totally opposed to things that would be good for those very voters? Why are these voters voting for something that's going to hurt them? Very thoughtful, I think, about --

MR.: What's the name of the book again?

DE FERRANTI: "Dear Hunting With Jesus." It's a community where people, you know, deer hunt and go to church.

(Cross talk.)

MR.: That sounds like a -- that sounds like it's similar to the one a couple of years ago about Kansas.

(Cross talk.)

MR. : "What's Wrong With Kansas" (sic).

DE FERRANTI: It's worth -- it's worth looking at.

Jim, good point. Like you, I, in years past, was absolutely livid about the amount of money being spent on older people. I've moderated my views. (Laughter.)

(Cross talk.)

DE FERRANTI: I'm not, again, optimistic that societies -- you're right, but this is the rational versus what actually happens. It looks to me, from experience, as though societies gravitate towards creative obfuscation about that question; that in the end there is rationing, and in the end we -- numbers of us die in our older years -- has to happen, not always fairly, and certainly very expensively. But I -- as soon as you work it out, Jim, give me a call. (Laughter.)

MR.: Give us all a call. (Laughter.)

DE FERRANTI: (Laughs.) And Robert, very good question. I think that the first question to ask is not necessarily about whether UHC should be part of any post-MDG goals, but should there be any post -- you hit it yourself. And there, we should ask the question: What have we learned from the experience of having MDG goals over this 15 years? Did things get better? And there certainly, if you look further back, is a -- is a long landscape of shattered dreams that would sober one about setting a goal.

HUANG: OK. Bill, do you want to add?

HSIAO: Just add quickly to Tom's question -- and Jim's -- is, I think the effort in the United States will come at the state level, not at the national level. That's because I observed the -- at the national level the -- there are so many powerful stakeholders that -- and with our check-and-balance political system, we won't be able to move there.

And I would urge you to look at what Vermont tried to do to introduce the single-payer system to -- as a model -- a vanguard for United States. And otherwise, I think we will have to work ourselves into a crisis or such. And my own guess, it will take eight years.


HSIAO: Eight, because of not next -- (inaudible) -- couple of cycles of election, but it's one after that then people get -- because a key group I observe is coming around are physicians. American physicians now say: No, this system is broken; we want change. Previously, physicians -- not on board. And that's a change. People and the business want change. The pharmaceutical industry, insurance industry, physicians and hospitals do not want the change, and -- but you see the key group is physicians are changing their views in America. That's a hopeful sign.

Jim's question about value of life and how people value their own life and would demand services, I really don't -- particularly with the aging population, I don't think there is a good answer. But I suggest there is a way out of it, particularly for developing countries. I would argue, if you observe foreign countries developing very rapidly, people's consumption is -- they will -- are willing to increase their change in the consumption patterns by about 2 (percent) to 3 percent per year. But if their growth of income is 5 percent, they're willing to put more money into savings.

I will argue, actually, we should get people to pre-fund their retirement health care and develop a mandatory savings fund. And then at the age 65, you actually purchase a so-called single premium, long-term care package, rather than shifting the -- taking the resources from the younger population and the children and women and so forth, for the elderly. And I think there's a lot of new thinking required.

(In terms of Bob's question ?), I think -- Robert -- he's a(n) international expert; I don't have anything to add. (Laughter.)

HUANG: Well, thank you. That wrap up our first meeting on the universal health coverage. I'd like to thank you, everyone, for coming and participating. And of course, thanks, Bill and David, for such absolutely fabulous discussion.

And I'd also like to thank Zoey (ph) and Jerusa (ph) that -- our research associates of our Global Health Program, for their support and make that meeting possible.

And I'd also like to, again, thank Robert and the Rockefeller Foundation for their support and I think they deserve applause. (Applause.)

Our second roundtable is going to be held in New York City on February 9th.

MS. : Yes.

HUANG: That's right. And the focus will be on sustaining health -- universal health coverage.

Thank you all again for coming.








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