Can the Cuban Universal Health System Work in the U.S?
When I traveled with a group of classmates to Cuba this January to explore the strengths and challenges of its universal healthcare system, we found that public health is a major priority and great source of national pride in Cuba. At each visit, we were told of Cuba’s impressive, U.S.-comparable achievements in health statistics, including low infant mortality and elimination of vertical HIV transmission.
However, some residents and reports say that even though Cubans receive free universal health care, education, and food rations, the salaries of the residents are abysmally low and opportunities for personal financial growth are limited. Though entrepreneurial opportunities are growing with President Raúl Castro's increasingly progressive economic policies, the overarching theme remains that most Cubans are quite healthy and well educated, but can barely afford to survive – a pervasive issue that drives some of the observed health trends, such as low or delayed fertility and high abortion rates.
In processing both sides of what we had heard from local health professionals, lay citizens, and international reports, my greatest takeaway from Cuba was that universal, convenient access to care—coupled with a cultural emphasis on health promotion, disease prevention, and social responsibility—can drive positive health outcomes, despite grave economic and political challenges.
Comparing Health Systems
As sexy as free, universal healthcare sounds, I immediately and cynically thought that this could never work in American society. Successful implementation in Cuba is predicated on an inherently paternalistic society, where Cuba has the force of the State to mandate, define, and institute a universal healthcare system. Cubans are willing to accept, or at least unable to challenge, their system.
In Cuba, economic and technological limitations are placed on the urgency around public health, not medical treatment. And Cuba is relatively classless: even its doctors, some of the highest paid professionals in Cuba, only make $50-$70 each month. Because Cubans are universally poor, there is less demand for choice, and thus, they have a greater propensity to accept a state-defined health plan and protocol. In essence, beggars can't be choosers.
The U.S., on the other hand, is an individualistic society fueled by private industry where the supreme desire is freedom of choice. As such, Americans are unlikely to favor a federally mandated, pre-fixe menu of locally assigned providers, designated treatment centers, preapproved services and therapies, and mandatory healthcare regimens. Americans are also resistant to policies that are viewed as infringing on their individual rights. Other issues include the prominence of private industry, our severe wealth inequality, and the decentralization of health care policies among the states, all of which create significant discrepancies in the availability and quality of care across the nation.
With these realities in mind, the question becomes how can we successfully integrate lessons from Cuba into the American health system, given the power of private industry in the U.S. health sector and its heavy focus on medicine and treatment? While I do not pretend to have the answer, I believe there are three lessons we can learn from Cuba’s success in public health:
1. Develop a culture of public health
Though the road to universal healthcare may be longer, more complicated, and require more compromise than we’d hope, as budding public health professionals, we can begin to shift cultural attitudes by placing a greater emphasis on prevention over treatment and fomenting social responsibility for health. To this end, we should work to strengthen the social fabric of our communities, which enables a leaner community-based network for health promotion and disease prevention.
2. Increase care providers’ role in health education
From what we saw, there is a heightened intimacy between patients and physicians in Cuba that has been developed through lifelong engagement, which is crucial to Cuba's public health education. Unfortunately, with constant patient migration, practice turnover, and the ability to cherry-pick from numerous providers, for many in the U.S., our relationship with our doctors are less intimate and more transactional.
Our face time with doctors has been cut shorter and shorter over the years, and we often see physicians as “diagnosers” and “treatment prescribers,” rather than trusted health advisors. As such, our most prominent and trusted high-touch champions – healthcare providers – are mostly reactive and often miss opportunities to educate individuals on healthy behaviors and risk mitigation.
We need to focus on rebuilding provider's advisory roles through mandatory, nationally coordinated health tutorials with patient visits and routine health briefings to recap health risks and recommendations. States or insurance companies could also employ program providers that would allow patients to participate in health education in exchange for insurance premium reductions or state tax credits.
3. Reinforce partnerships with business
As a person with a finance background, what struck me most about class discussions with peers during my first year at Mailman was their heavy, anti-corporation sentiment. While there certainly needs to be discussion of corporations’ role and accountability in negative health outcomes, complete demonization of big business is wholly counterproductive.
Cuba is able to achieve tremendous success in public health due to the dominance of the state and the minimization of private influence, resulting in uniform messaging, nationally mandated health programs and protocols, and absolute power to enforce mandates. Contrary to this, as Professor Michael Sparer explained to us at the conclusion of the Law & Public Policy module of the CORE, public health struggles to gain public support in America due to its lack of political power, especially in the face of powerful private industry.
Since a non-profit U.S. health system is unlikely to happen anytime soon, it is more advantageous that we leverage the reach, resources, and social influence of big business to promote health more broadly. Most corporations outside of the biotech and pharmaceutical industries know that it is more profitable to have healthy employees and healthy consumers—with some employers even offering credits to employees who practice healthy behaviors or participate in health education activities. We can gain greater corporate support of public health initiatives by emphasizing that good public health is both socially responsible and profitable for their business.
Most importantly, rather than creating tension with adversarial attitudes and inflammatory language, public health professionals should seek strategic partnerships with businesses that position us to better influence their ideologies, behaviors, and offerings—especially where political power is lacking. To achieve the most benefit, we should leverage the resources of private corporations to promote health and prevent disease. At times, we do need to challenge corporations, but that we shouldn't let our differences preclude us from collaborating with each other, because in each other, we can find valuable and necessary allies.
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