Paying for Care: Public Health Insurance Programs Around the World

The starting point is Germany's statutory system, which traces to the social insurance legislation of Chancellor Otto von Bismarck in 1883 and is described as the oldest national social health insurance system in the world. Care is delivered through roughly 110 competing nonprofit sickness funds rather than a single government insurer.

Japan reached universal health coverage in 1961 when its National Health Insurance system was established, built on an earlier 1922 law. It is run by municipal governments and covers people outside employer-based plans, such as the self-employed, retirees and farmers.

Medicare was created in 1965 when President Lyndon Johnson signed the Social Security Amendments. It covers Americans aged 65 and older and some younger people with disabilities, and is administered by the Centers for Medicare and Medicaid Services.

Enacted alongside Medicare in 1965, Medicaid is a joint federal and state program for low-income people. Each state sets its own eligibility and benefits above a federal minimum, which is why coverage varies so widely from state to state.

Taiwan launched its single-payer National Health Insurance on March 1, 1995, replacing a fragmented set of earlier schemes. By the end of 2023 enrollment had reached 99.9 percent of the population, with administrative costs of about 2 percent of spending.

Thailand rolled out its Universal Coverage Scheme nationwide in April 2002 under the promise that 30 baht treats all diseases. In 2006 the flat fee was dropped, making care free at the point of use, and the scheme is funded directly from the national budget.

Ghana established its National Health Insurance Scheme in 2003 to replace the cash-and-carry system in which patients paid at the point of care. A dedicated levy added to value-added tax is its main funding source, with exemptions for children, the elderly, pregnant women and the very poor.

Rwanda's community-based mutuelles were piloted in three districts in 1999 and made available nationwide by the mid-2000s. They are owned and managed at district level and let low-income households pool small premiums, with coverage rising to more than 90 percent of the population by 2020.

Mexico created Seguro Popular in 2004 for people working outside formal employment who were excluded from the social security health institutes. It is a cautionary stop because the government closed it in 2020 and replaced it with a new institute, amid debate over uneven implementation.

Signed by President Barack Obama on March 23, 2010, the Affordable Care Act created regulated insurance marketplaces, premium tax credits and a Medicaid expansion for states that adopted it. By 2016 the uninsured share of the United States population had roughly halved.

Indonesia launched Jaminan Kesehatan Nasional in January 2014, run by the social security agency BPJS Kesehatan. Enrollment grew from 48 percent of the population at launch to an estimated 83 percent by 2020, financed by payroll contributions and fixed monthly premiums from informal workers.