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Study: Thailand Achieves Near-Universal Healthcare

Ben Cole, for HealthLeaders Media, April 7, 2009

As President Obama's administration continues its efforts to find common ground with opponents to provide universal healthcare for an entire country, one recent study has found it can be done.

According to a study published online by Health Affairs, Thailand has achieved near-universal health coverage through its 2001 health reforms. When implemented, the "30-baht health scheme" was designed to provide equal access to quality care regardless of income or socioeconomic status. One important aspect of the plan was that no individual would be required to spend more than 30 baht, or about 84 cents, per visit for either inpatient or outpatient care, including drugs.

The program seems to be working, according to the study's findings: Health Affairs data through 2005 found the 30 baht system moved toward universal coverage by adding 13.6 million previously uninsured people into the system, resulting in a coverage rate of 95.6%.

In addition, the vast majority of people covered under the 30 baht system pay nothing out of pocket for outpatient care, the study found.

As for the remaining 4.4%, the study's authors contend that lack of awareness, an absence of an identification card, and incorrect housing registration are all reasons for those left off of the rolls. One would hope that given the hype surrounding health reform in the U.S. and superior tracking systems, this would not be a problem if we ever get around to providing universal coverage.

But as the study's authors note, the expansion of government-financed health insurance programs face several potential problems. One is the emergence of informal, under-the-table payments collected by healthcare providers. Although these payments are illegal, they are often ignored by governments because they represent a source of additional financing to supplement subsidies offered by governments that may be trying to offer universal coverage but do not have the resources or political support to fund the program, say the study's authors.

"Such payments represent a large fraction of spending in some countries and are fairly widespread, especially in Asia," the authors say.

Another potential problem when rapidly expanding coverage to a large group of previously uninsured people is an immediate spike in demand despite a fixed supply of healthcare services—at least in the short term. This can lead to "queuing," the authors say, or lead to a reduction in access to care for those already in the system as well as those who recently joined it.

Thailand has avoided these problems, at least thus far, according to the study. There is no evidence that the informal, under-the-table payments seen in other Asian countries has arisen in Thailand, say the study's authors. Access to care also improved for the previously uninsured, while at the same time access does not seem to have decreased for those already in the system. Lastly, the authors note that the newly insured group has better access to care after the advent of universal coverage than it had before.

So how did Thailand avoid such problems? The authors suggest that one possibility was the country's use of the targeted payer payment system, which pays capitation directly to the clinics and hospitals that sign up to serve patients.

"This approach ensures that the funding goes directly to the facilities that have the most patients, providing them with incentives to sign up patients and the financial resources needed to add staff and other resources as needed," according to the study.

The authors admit that there were limitations to the study, and that quality of care, waiting times, satisfaction, and long-term sustainability were all dimensions of the program that need to be explored. But there is no doubt that in a few short years, Thailand has achieved what it set out to do: Provide comprehensive, affordable, quality healthcare to (virtually) all of the country's residents.

While the innumerable differences between the U.S. and Thailand health systems make it impossible for the U.S. to try to emulate Thailand's reforms, there are some lessons Americans can take from Thailand's ambitious program.

Opponents of Obama's lofty reform plans often cite they will result in socialized medicine and, as the Thailand study authors mentioned, the risk of inundating an already overly burdened healthcare system with the newly insured. But as the Health Affairs study shows, if the country has a clearly defined goal and buy-in from every aspect of the industry, it can be done.

The study also shows that it will take time—Thailand is much smaller than the U.S. and it took several years before it achieved near-universal coverage. Critical stakeholders in the U.S., as well as consumers, need to understand that the country's health reform will not happen overnight, and realize that an extended effort that will likely require adjustments will eventually benefit everyone involved by providing affordable, quality healthcare for all.


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Ben Cole is an associate online editor with HealthLeaders Media. He can be reached at bcole@healthleadersmedia.com.

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