--:-- Sean Rameswaram: Support for this show comes from ServiceNow. AI is only as powerful as the platform it's built into, don't you know? That's why it's no surprise that more than 85% of the Fortune 500 use the ServiceNow AI platform.
--:-- Dylan Scott: Didn't know that. While other platforms duct tape tools together, ServiceNow seamlessly unifies people, data, workflows, and AI, connecting every corner of your business. And with AI agents working together autonomously, anyone in any department can focus on the work that matters most.
--:-- Sean Rameswaram: I've never met an AI agent. Learn how ServiceNow puts AI to work for people at servicenow.com.
--:-- Dylan Scott: Support for this show comes from Macy's. Layering is an art form. All it takes is a bit of intention, style, and, of course, the perfect cold weather staples.
--:-- Sean Rameswaram: So, talk to me about Taipei. Do I have to?
--:-- Dylan Scott: Yes! It's hot. It's bustling for sure.
--:-- Sean Rameswaram: Wait, Dylan, why are we in Taipei again?
--:-- Dylan Scott: So, my colleague Bird Pinkerton and I went to Taiwan for this series of stories on international health systems. I think this is the hospital. And we had this appointment with a college professor, but we needed to kill some time beforehand. And his office just so happened to be right next to the National Taiwan University Hospital in downtown Taipei.
--:-- Sean Rameswaram: We've got an hour and a half. We see as much as we can. So, what'd you see when you went inside?
--:-- Dylan Scott: It was really crowded inside. Teaming with people. Like, there was the opening registration lobby, which was just big, kind of open room, and there were, like, buzzers pinging all the time. Press a button, take a number. People getting their numbers called. Like, there seemed to be a lot of patients at this hospital looking to get treated.
--:-- Sean Rameswaram: Taiwanese want their health care. But there was one exception. The one place that seems kind of empty and very slow is the cashier's desk. They did have a cashier's desk. It's basically empty. You could have seen a tumbleweed blowing through.
--:-- Dylan Scott: Why were there no people at the cashier line, Dylan?
--:-- Sean Rameswaram: So, Taiwan has a national health insurance plan. One public program that covers everybody. And under that public program that covers everybody, when people go to the doctor or people go to the hospital, they have to pay either nothing at all or very little of their own money to get the medical care that they need.
--:-- Dylan Scott: So, you're not going to see people, you know, standing at the cashier's desk, haggling with some poor hospital assistant trying to figure out what they pay, because Taiwan has come up with this system where everybody's covered, and the actual cost of medical care at the point of service is very low.
--:-- Sean Rameswaram: Dylan Scott reports on healthcare at Vox, and he's been working on a series called Everybody Covered. It's a look at what the United States can learn from other countries' healthcare systems. You will surely be hearing more about Medicare for All from the Democratic candidates at tonight's debate, but today on the show, we're going to take you to two other countries to find out how their universal coverage works. Taiwan's fully public system and the Netherlands fully private system. We're going to start with Taiwan.
--:-- Dylan Scott: If you're a Taiwanese citizen or if you live in Taiwan, you get a health insurance card from the government and it covers your benefits for almost all of the medical needs that you would have. You know, going to the primary care doctor, seeing specialists, going to the hospitals, medications and prescriptions. It's really only certain things like cosmetic surgery or more elective things that aren't covered by the national health insurance plan.
--:-- Sean Rameswaram: But, Dylan, whenever you see the Democratic debates, all the candidates are going back and forth about how you're going to pay for Medicare for all this multi trillion dollar hole, 3.4 trillion a year, it turns out costs are going to go up. I don't know. My parents always told me that nothing in life is free.
--:-- Dylan Scott: So, like compared to what we have, this, you know, Frankenstein system we have in the U.S., what Taiwan's doing is actually quite cheap and more efficient. And so Taiwan spends about 6% of their GDP on healthcare and the United States spends over 17%.
--:-- Sean Rameswaram: And should I assume that like everyone in Taiwan loves this system?
--:-- Dylan Scott: It is really popular, at least according to the surveys that some government officials showed us while we were there. Once people got insurance and once they started using their benefits, its popularity rapidly increased and it stayed high over time. These days it hovers somewhere around 80 percent.
--:-- Sean Rameswaram: And I think that a number that sticks out even compared to sort of other developed economies and certainly compared to the United States.
--:-- Dylan Scott: But you did say that hospital was really busy the one you went to right? Are they all like that or was it just the one?
--:-- Sean Rameswaram: The big hospitals, they're always crowded. We actually talked to a researcher named Xuxia Chang who has studied this. And he told us that there's so many people waiting, want to see the adapter. That's the situation in Taiwan. It's a big problem for Taiwanese health care everywhere that patients use a lot of health care, and that tends to mean that hospitals are crowded and doctors feel overworked.
--:-- Dylan Scott: My Canadian family says the same thing about their system. Oh, it takes forever to get something done. There's such a weight. There's such a weight. Right. And this is sort of, you know, if you think about health care from an economic point of view, this is one of the concerns. Like, if you give everybody insurance, if you tell them you don't really have to pay any money when you go to the hospital or go to the doctor, then they're going to go to the hospital and go to the doctor.
--:-- Sean Rameswaram: And then it becomes harder for the providers, the people on the supply side, to meet that demand. If the patients are too satisfied and the doctors are very unsatisfied, they're unhappy, how can you expect the system to be sustainable?
--:-- Dylan Scott: And so what we've heard from Xochitl Chang and from others is that, like, that is one of the fundamental problems that the Taiwanese system has always struggled with, is how to make sure that there are enough doctors, enough hospitals available to treat everybody who needs it.
--:-- Sean Rameswaram: We actually met with two doctors in a coffee shop in Taipei, and they were members of this medical labor union that was formed a little less than a decade ago, I think in response to some of these concerns in the medical profession about how national health insurance was affecting their quality of work. One of them was named Max, and he was dressed in this, like, dapper newsboy cap.
--:-- Dylan Scott: And he told us that, like, I'm a little bit, you know, lefty. He thought of himself as a political lefty, but he was also, like, clearly overwhelmed as a doctor working in the National Health Insurance Program. Because you got very limited resources to do the crazy job.
--:-- Sean Rameswaram: So, Max actually works in an emergency room, and he would tell us that people would just come in all the time for every little thing. Some people abuse the emergency, abuse the health care.
--:-- Dylan Scott: Taipei, you know, very densely packed urban city. You know, there's a lot of herds of scooters and people just zooming down the street. And so you can imagine at a, like, major trauma center in a city like that, like, you're dealing with accidents and broken bones and all kinds of sort of serious medical trauma all the time.
--:-- Sean Rameswaram: And yet at the same time, because patients had so little sort of incentive to, like, be thoughtful about how they use health care, somebody would also just, like, walk into the emergency room because, like, my wrist hurts or something that's not necessarily actually that serious.
--:-- Dylan Scott: But under the Taiwanese system, it doesn't really make that difference to that patient, whether they go to the ER or whether they go to their primary care doctor. How could we differentiate really medical need or just some people want?
--:-- Sean Rameswaram: Yeah, yeah. You'll read my heart. One really vivid picture that Max painted for us was he told us... In Taiwan, the doctor is in hell and the patient is in heaven. In Taiwan, the patients are in heaven and the doctors are in hell.
--:-- Dylan Scott: And that was how he saw it as a doctor practicing in Taiwan. And, you know, every health system comes with trade-offs, and I think that speaks to the ones that Taiwan has settled on. We want it to be really easy for the patients, but that means we're going to put a strain on our providers too.
--:-- Sean Rameswaram: Okay, so while the system is immensely popular, it's imperfect, are there any alternatives? There are. There are countries like the Netherlands that instead of having public insurance for everybody, they've got private insurance for everybody. Can we go there, too? Let's. After the break on Today Explained.
--:-- [Break music plays]
--:-- Sean Rameswaram: Support for Today Explained comes from Chime. Nobody likes fees and complicated banking, says Chime. And Chime gets that, says Chime. Chime is a financial technology company that says they understand that every dollar counts.
--:-- Dylan Scott: So when you set up direct deposit through Chime, they say you get access to fee-free features such as free overdraft coverage, getting paid up to two days early with direct deposit, so much more.
--:-- Sean Rameswaram: Chime says with qualifying direct deposits, you can be eligible for free overdraft up to $200 on debit card purchases and cash withdrawals. Plus, they say you don't need to worry about monthly fees or maintenance fees.
--:-- Dylan Scott: You can work on your financial goals through Chime today. You can open an account in two minutes at Chime.com slash explained.
--:-- Sean Rameswaram: That's Chime.com slash explained. Chime feels like progress. Chime is a financial technology company, not a bank. Banking services and debit card provided by the Bancor Bank N.A. or Stride Bank N.A. Members FDIC.
--:-- Dylan Scott: Spot me eligibility requirements and overdraft limits apply. Timing depends on submission of payment file. Fees apply at out-of-network ATMs. Bank ranking and number of ATMs according to U.S. News and World Report 2023. Chime checking account required.
--:-- Sean Rameswaram: Let's be honest. Are you happy with your job Like really happy The unfortunate fact is that a huge number of people can say yes to that Far too many of us are stuck in a job we outgrown or one we never wanted in the first place.
--:-- Dylan Scott: But still, we stick it out, and we give reasons like, what if the next move is even worse? I've already put years into this place, and maybe the most common one, isn't everyone kind of miserable at work?
--:-- Sean Rameswaram: But there's a difference between reasons for staying and excuses for not leaving. It's time to get unstuck. It's time for Strawberry.me. They match you with a certified career coach who helps you go from where you are to where you actually want to be.
--:-- Dylan Scott: Your coach helps you get clear on your goals, create a plan, build your confidence, and keeps you accountable along the way.
--:-- Sean Rameswaram: So don't leave your career to chance. Take action and own your future with a professional coach in your corner. Go to strawberry.me slash unstuck to claim a special offer. That's strawberry.me slash unstuck.
--:-- Dylan Scott: So, Dylan Scott, healthcare reporter here at Vox, champion of the Everybody Covered series. Here we are, standing in the Netherlands. Look at that. Some people are biking by. Oh, oh, and a canal. Look, a rowboat going through the canal. Shall we go eat some frites?
--:-- Sean Rameswaram: We can, I guess. You know, I have to say that the only thing I was disappointed in in my trip to the Netherlands was the food. But did you notice the health care they've got over there?
--:-- Dylan Scott: So, yes, the Dutch have a universal health care system that in some ways is the polar opposite of the system in Taiwan. So instead of universal public health insurance where everybody gets an insurance plan from the government, which is what the Taiwanese have, the Netherlands has private health insurance for everybody. So everybody gets coverage, but you buy it from a private health insurer instead of the government.
--:-- Sean Rameswaram: Explain to the folks at home and me, because I don't know, how a fully private but fully funded universal health care works.
--:-- Dylan Scott: So... I might get into the details. I hope you don't mind. The Dutch system actually shares some important characteristics with Obamacare that a lot of people are probably familiar with. You've heard a lot about it since I signed it into law.
--:-- Sean Rameswaram: So they have bans on pre-existing conditions. We're not going to go back to a time when people's coverage was dropped when they got sick. They have an individual mandate. So if you don't sign up for insurance, they'll fine you twice. And then they'll just automatically enroll you in an insurance plan and start garnishing your wages to pay for it.
--:-- Dylan Scott: Thanks, Obama. And they have a lot of government assistance. So you could shop for a plan that fits your needs. And then we would give you tax credits to help you buy it. Like the government provides a lot of funding to help keep premiums affordable for people. That means it's less than your cell phone bill, because I know you guys are tweeting a lot. And texting and selfies.
--:-- Sean Rameswaram: Now, the Dutch system goes beyond Obamacare in a couple of important ways. So let's start with a basic fact. The majority of Americans do not — let me repeat — do not get healthcare through the Affordable Care Act. This is like Obamacare for everybody, not just for, you know, the 10 million or so people who buy insurance on the individual market here in the United States.
--:-- Dylan Scott: Everybody in the Netherlands gets their health insurance through this private market. And the government plays a much more active role than even the U.S. does through Obamacare.
--:-- Sean Rameswaram: So in Taiwan, you had the system where everyone goes to the ER because they don't have to pay for it. Do people in the Netherlands not go to the ER because they have to pay for it?
--:-- Dylan Scott: Yes. So the Dutch have actually tried to design their system so that people are a little more rational about how they use their health care. So for Dutch patients, if you go see your primary care doctor, it's free. You don't have to pay anything. You just show up. You walk out without a bill.
--:-- Sean Rameswaram: But if you go to the emergency room, you have to pay towards your annual deductible, which is capped at about 385 euros a year. Something like 420 US dollars.
--:-- Dylan Scott: That's 420, Dylan. Basically, if you're somebody who's like sitting there, you've got something that feels kind of wrong, but you're not sure. You have a choice between either going to the ER, which will cost you like 400 bucks, or you could go to your GP and you can get treated for free.
--:-- Sean Rameswaram: But does that mean that people who like accidentally chop off their left forearm are like going to their GP to be like, help. I can't answer that hypothetical, vivid though it is specifically.
--:-- Dylan Scott: But I will say doctors in the Netherlands are more likely to say that their patients have a higher cost burden, like it's harder for them to afford their medications or pay for medical care if they do need to pay for it than people in other countries.
--:-- Sean Rameswaram: How long have they had this system So they overhauled their system in 2006.
--:-- Dylan Scott: Have they figured out any ways to sort of work out the kinks in it Maybe people avoiding going to the ER people overburdening their GPs Yes.
--:-- Sean Rameswaram: So one place where this all kind of comes to a head is like, what if somebody needs medical care outside of normal business hours? What do they do?
--:-- Dylan Scott: I think in the United States, a lot of people are just like, well, I'm going to go to the ER. But like the Dutch are trying to avoid that. So what Dutch doctors have done is set up these cooperatives where a bunch of Dutch primary care doctors will team up basically and they'll pull all their patients together and they'll give them a number and say like, if you have a problem after hours, you can call this number and there will be a doctor who can handle your question over the phone.
--:-- Sean Rameswaram: And, you know, if you're, like, chronically ill or you have, like, a disability or you're elderly and it's hard for you to get out of the house, they'll even have a doctor who's out in an SUV roaming around the countryside ready to make home visits for patients who need it.
--:-- Dylan Scott: Tell me you went for a ride in that Dutch SUV, Dylan.
--:-- Sean Rameswaram: Oh, yeah. We were out on the road for, like, four hours. So this doctor, Elise, it was her job that night to go out on home visits. So she and her driver, Henry, checked to make sure they had everything they needed. And then they hopped in and me and our photographer for the Dutch story got in the back and we were off.
--:-- Sean Rameswaram: And so the first place that we stopped, I think, is a nice example of like how this after hours care program is really supposed to work. We were going to see this guy who had called because he was feeling a lot of pain. and we parked kind of down an alley a little bit, like away from the main road, along this like block of row houses.
--:-- Dylan Scott: Elise got out to see this patient, this older man who was experiencing a lot of pain, but after she did her exam, her checks on him, she was like, you know, this really isn't serious enough for you to go to the emergency room.
--:-- Sean Rameswaram: So she told him that there were some diagnostic tests that he should get done. and that he should call his regular primary care doctor, one of Elise's colleagues in the co-op, the next day.
--:-- Dylan Scott: And so this guy who'd been in pain had gotten to see a doctor. He'd gotten some fresh medical advice and a writ to follow up with his regular doctor the next day. But he didn't have to leave his house. He didn't have to drag himself to the emergency room. And the care that he got provided was free to him.
--:-- Sean Rameswaram: So this co-op idea for me was sort of a perfect example of the Dutch way of thinking about health care. How do the people like the system?
--:-- Dylan Scott: It's still relatively new. So I think on the whole, like the Dutch are proud of their system. It was abundantly clear from all the people that I was visiting with that they're really proud of how they've managed to organize a health care system that often kind of depends on individuals or private actors.
--:-- Sean Rameswaram: But that, you know, having a health system built on those foundations is also going to come with some downsides.
--:-- Dylan Scott: Okay, so we've heard about two systems. We heard that they both have flaws and they're both well-liked by some of the citizens who use them. What do you think works best? I mean, at the end of the day, you're just like, you know, that American system is actually looking pretty good right now.
--:-- Sean Rameswaram: So that would never be my conclusion. The American system did not look better in any respect.
--:-- Dylan Scott: But the way I think of it is more every system is going to have its tradeoffs. So in Taiwan, it's really easy for the patient for the most part, right? Like costs are really low. You can go to the doctor for free. But the tradeoff for that is that the doctors feel really overwhelmed and stressed.
--:-- Sean Rameswaram: And the Netherlands, on the other hand, like they've done a pretty good job of managing how people use health care and imposing this cost-sharing to try to encourage people to be more rational about how they use their health care.
--:-- Dylan Scott: But that makes it harder on the patients because, you know, if you make the mistake of going to the ER when you shouldn't, suddenly you're out $400 when if you had gone to your GP, it would have been free.
--:-- Sean Rameswaram: And so I think it's up to every country to try to decide which of those kinds of tradeoffs are more acceptable to us.
--:-- Dylan Scott: What distinguishes the United States is we have not reached sort of the collective understanding that both Taiwan and the Netherlands have that everybody should have healthcare in the first place.
--:-- Sean Rameswaram: And so I think that's where we fall short. But once you've decided to build a universal health system, it's about figuring out which of those tradeoffs are more acceptable based on what patients want, what doctors want, and balancing the interests of the two.
--:-- Dylan Scott: Well, maybe we'll get there one day, Dylan.
--:-- Sean Rameswaram: Yeah, maybe. Dylan Scott, he's a reporter at Vox who covers healthcare. You can find his Everybody Covered series at vox.com. He and producer Bird Pinkerton also made a version of this story for the Impact podcast. You can find that wherever you're listening to this.
--:-- Sean Rameswaram: I'm Sean Ramos for him. It's Today Explained. Thank you.
