Health reform Russian style – a brief primer on Putincare
Donald Trump has expressed admiration for Russian president Vladimir Putin, calling him “bright and talented” and a “strong leader.” With praise like that, we may wonder whether Trump would follow Putin’s lead in formulating policies as president. And if he did, what are the policies that the object of his admiration has pursued?
Donald Trump has expressed admiration for Russian president Vladimir Putin, calling him "bright and talented" and a "strong leader."
With praise like that, we may wonder whether Trump would follow Putin's lead in formulating policies as president. And if he did, what are the policies that the object of his admiration has pursued?
Putin's policies in the sphere of foreign relations are fairly clear, especially as they relate to a few global trouble spots like Ukraine and Syria. What about on the domestic front? What course has he followed in the economic and social spheres?
Health care is a good place to look, as it affects everyone and has been a defining issue recently in American politics. Trump has yet to offer any policy details in that area, so possible clues to his thinking would be especially valuable.
What, then, does Putincare look like?
On the surface, it shares many features with the U.S. system, including some that may seem similar to Obamacare. However, for all the problems the U.S. system faces, Russia's are magnified many times.
In 2000, the World Health Organization ranked Russia's system 130th out of 190. (The United States came in at number 37.) It saw some improvement in the 2000s after serious disruptions during the transition from Soviet rule in the 1990s. But today, many observers see it as back in a state of crisis.
The constitution of the Russian Federation, of which Russia is a part, grants all citizens the right to free health care, a holdover from the Soviet era. Under post-Soviet reforms, the system became more decentralized, with new roles for regional governments and private companies.
Financing is through a system of mandatory insurance that requires all citizens to choose a policy, with the government paying the cost. Funding comes from a combination of federal, regional and municipal budgets, a payroll tax, and a tax on insurance.
However, individuals bear an extraordinarily large and growing share of the financial burden. They pay 36.6% of the country's total spending out-of-pocket, almost triple the 13% in the U.S. Insurance does not cover many basic items, including prescription drugs. Physicians often demand under-the-table payments in addition to insurance reimbursement before they will provide care, and patients often resort to soliciting donations when advanced care is needed.
The federal government owns 95% of all hospitals, but many Russians avoid them because of poor quality. Most physicians work for the government, and salaries are among the lowest in the world.
Yet, in a ranking of major countries in 2013, Russia still had the third highest number of physicians per 1,000 people, 4.9, while the United States had only 2.6. The average Russian saw a physician 10.5 times a year, almost double the 4.0 visits of the average American. Russia had 9.1 hospital beds per 1,000 people, the third highest, compared to only 2.9 in the U.S. It also had the third highest number of annual hospital discharges, 235 per 1,000, compared to 125 in the U.S.
However, Russia spends very little on health care overall. It consumed just 6.5% of GDP in 2013 compared to 18.4% in the United States and a worldwide average of 8.9%. That translated into $1,653 per capita, compared to $8,713 in the U.S. and a worldwide average of $3,453.
Many criticize the U.S. figure as too high, but Russian spending is dangerously low, and some blame it for the country's dismal health outcomes. The rankings placed its life expectancy as third lowest, 70.7 years, compared to 78.8 in the U.S. It has risen only slightly since 1970. Infant mortality was more than two times the world average and tenth worst of any major country at 8.2 per thousand. It was 5.0 in the U.S.
In terms of public health, alcohol consumption was ranked fifth highest, averaging about 11 liters per person compared to a little more than eight in the U.S., an increase of about 10% since 2000. On the bright side, only 19.6% of people age 15 and over were obese, which was slightly above average, while the figure in the United States was 35.3%.
With poor health and a low fertility rate, Russia's population has been shrinking. It fell from about 149 million to about 145 million between 1993 and 2015. Predictions are that it may fall to as low as 100 million by 2050.
To combat a surge in costs, Putin recently promulgated a number of reforms. They include pledges to increase health care funding, double physician salaries, and speed up privatization.
However, rather than stabilizing the system, the reforms have led it back into chaos. In 2014, they resulted in the widespread closure of hospitals, including 28 in Moscow, and to the firing of thousands of health care workers in what government officials have called "optimization" of resources. Huge street protests by physicians and patients followed. Other cost-cutting measures in outlying regions have encountered similar resistance in what has been described as a "social revolt."
While Trump has been light on details, he says that he supports universal health care coverage in concept with the government paying the cost. At the same time, the foreign leader he so admires has had significant difficulty achieving that goal, even under a constitutional obligation, and has led the system to state of crisis. Hardly the results one would hope for from a "bright and talented" leader.
Would Trump follow a different path from Putin in health care, or would the Russian leader be his guide? We are waiting to hear.
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