By: Zachary Outzen (see full bio at end of article)
Regarding universal healthcare, Americans seem to be longing for something that is always out of reach. It is no secret that the United States (U.S.) lags behind other wealthy nations in guaranteeing universal healthcare coverage. Compared to other peer nations, the U.S. predominately relies on private employers to provide health insurance, with discouraging results.[1] In a study by the Commonwealth Fund examining eleven high-income countries, the U.S. ranked dead last in equitable access to affordable, quality healthcare.[2] The factor most determinative of access to such care in the U.S. is how much one earns.[3] Even then, high-income earners in the U.S. experienced more financial barriers to healthcare access than low-income individuals in the other ten nations surveyed.[4]
Astonishing inefficiencies compound our startling inequities. The U.S. spends more money on healthcare per person than any other wealthy nation.[5] This disparity is partly a result of the bureaucracy inherent in our complex system: the U.S. spends the most per capita on administrative costs relative to any wealthy nation while spending less per capita on preventative and long-term care than the average developed country.[6] For our effort, we are rewarded with significantly worse health outcomes, with lower life expectancy and higher infant mortality than most developed countries.[7] Adding insult to injury, profit incentives and lack of price controls in the U.S. healthcare system enable medical and pharmaceutical companies to transfer the cost of innovation and research to American consumers; not only do they make more money in the U.S., these companies then effectively subsidize the development of drugs and technologies to be sold for “scraps” in other countries.[8]
Americans, who live the reality of our inequitable and inefficient healthcare system, strongly desire political action to fix it. The 2020 Democratic presidential primaries were marked by a single-minded focus on the debate between “Medicare-for-All” and a “public option,” with a candidate’s position serving as a litmus test for how seriously their administration promised to take healthcare reform.[9] The COVID-19 pandemic added further urgency in the public’s mind to healthcare reform. 63% of Americans from all ends of the political spectrum now believe that the government is responsible for providing universal healthcare coverage.[10]
Yet, despite having a significant problem and a strong desire for a corresponding policy intervention, our healthcare politics are stuck. The Affordable Care Act (“ACA”), which narrowly passed in 2010 by a Democratic Party coalition led by President Obama, represented the most significant expansion of healthcare access in modern American history. That year, the Democrats were rewarded for their effort with one of the most bombastic midterm election losses in history, with sixty-four Democrats losing their congressional seats to Republicans who campaigned on attacking the ACA as a “boondoggle.”[11] Yet, eight years later, Republicans suffered a similar cataclysmic midterm loss after attempting and failing to repeal the ACA, in part due to a favorable shift in public perception of its provisions.[12] For elected officials, the incentive structure is clear. Transformative change in the healthcare system risks an evident electoral backlash.[13]
As a result, the struggle over universal coverage in the U.S. now primarily plays out in incremental steps, generally through processes shielded from the eyes of voters. These gradual changes mostly tinker, in a technocratic fashion, with the contours of the ACA’s marketplace exchanges.[14],[15] While the ACA remains an undeniably beneficial program for access to healthcare, its limitations in treating healthcare coverage as a consumer good are just as plain. Private insurers participating in the exchange generally cover a narrow set of healthcare providers, systematically excluding access to specialists such as pediatricians, oncologists, and mental health providers.[16] Marketplace “customers” almost always cannot tell how broad a plan’s covered provider network is.[17] Even if that information were available, it is class-blind to believe that the ability to pay more for additional providers is a simple decision. As Professor Frank Pasquale of Brooklyn Law School notes,
“The choice to spend $200 more a month, say, to cover the best cancer specialists in case of an unexpected diagnosis, means very little to someone with $5 million in brokerage accounts (why not splurge?), may be very difficult for someone with $20,000 in the bank (who could increase their net worth significantly by opting for the cheaper plan), and may not exist at all for someone living paycheck to paycheck.”[18]
How do we break out of this cycle of endless healthcare market design when so much more is wanted and needed? As Professor Pasquale also contends, more scholarly attention should be directed to analyzing how other advanced, industrialized nations have successfully covered significantly more individuals at substantially less cost.[19] In other words, a comparative legal analysis may hold the key to understanding how our healthcare laws – which shape the political economy of the healthcare system – can chart a course towards a “fair and just transition to universal [healthcare] coverage.”[20]
This essay attempts to do so by analyzing one country in particular – Türkiye – and its transition to universal healthcare coverage. Although their transition was complex and multifaceted, one specific component of their healthcare system, the Family Medicine Programme, is especially illustrative. This essay will discuss the law and implementation of the Family Medicine Programme, then reevaluate existing laws and institutions in America (namely, the U.S. Department of Veterans Affairs) that could pilot a similar transition to universal healthcare access.
Overview
The Turkish healthcare system distinctly provides a mix of public and private institutions––the Ministry of Health delivers nationalized services to all eligible citizens, while universities and the private sector offer alternative options for care.[21] The Turkish government is a single-payer insurer and dominant healthcare provider through the Social Security Institution (“SSI”), which finances healthcare provision. At the same time, the Ministry of Health provides primary, secondary, and tertiary care through Ministry-run facilities.[22]
A vital feature of the Turkish healthcare system is the Family Medicine Program, which provides various preventative and primary healthcare services free of charge at Ministry-run facilities.[23] Under the Program, each Turkish citizen is assigned a family physician who provides care at easily accessible walk-in clinics known as Family & Community Health Centers.[24] These Centers, now the main primary care provider in Türkiye, provide a comprehensive range of services.[25] They include preventative care services, inpatient and outpatient primary and urgent care, women’s and maternal healthcare, and dental care, to name a few.[26] Family physicians provide mobile services as well, traveling to rural areas, prisons, and nursing homes, and provide homecare services for those unable to walk into a clinic.[27] Outside of these Centers, emergency and ambulatory services are freely accessible, whether receiving care at a government-run facility or private hospital.[28] Catastrophic care, such as intensive care, cardiovascular surgery, renal care, and cancer treatment, are provided free of charge.[29]
For the citizens of Türkiye, the return on investment has been tremendous. In 2019, Türkiye spent roughly $395 per capita, compared to the U.S.’s $11,702.[30] A study shows that the Family Medicine Program decreased the mortality rate by 25.6% among infants, 7.7% among the elderly, and 22.9% among children ages one through four.[31] Between 1995 and 2017, maternal mortality decreased from 61 deaths per 100,000 live births to 17.[32] For reference, the U.S. maternal mortality rate in 2017 was 19.[33]
Besides its efficacy, the Turkish healthcare system is worth studying for comparison because, unlike many other universal healthcare systems, it successfully transitioned from a fragmented system into socialized, universal coverage beginning in 2003.[34] This is valuable because other universal healthcare systems, such as the United Kingdom’s National Health Service, were designed as such since the end of World War Two.[35] At that time, while Western European peer nations were implementing universal healthcare policies, “an accident of history” created our employer-based insurance system and the resulting bureaucratic accretion.[36] Thus, the most intuitive points of comparison from Western European nations are less practical, as they show us how to build a healthcare system from scratch rather than transform one entirely.
Türkiye, on the other hand, had not fully implemented a universal or single-payer healthcare system during this period. In 1945, the first social health insurance program was introduced, but only covered blue-collar laborers, and later, another program was created for retired civil servants.[37] The Ministry of Health began to operate state-run health facilities in 1961, although they were not available nationwide until 1983.[38] Over the next two decades, two more insurance programs – one for artists and the self-employed, another for the indigent – were created.[39] Between 1990 and 2002, several coalition governments struggled with inflation and political instability, with health reform falling by the wayside.[40] By 2003, there were a total of four government health insurers and a network of state-run facilities, with universities and the private sector providing a significant portion of services.[41] Despite this, the health system “faced insufficient and inequitable financing, a shortage and inequitable distribution of physical infrastructure and human resources, disparate health outcomes, and public dissatisfaction.”[42]
In 2003, a new political majority took power and concentrated on transforming the Turkish healthcare system, launching the Health Transformation Programme. The Programme began under the purview of the Ministry of Health. A working group composed of the Minister of Health, undersecretaries and deputy undersecretaries of health, and departmental directors began designing and planning the HTP.[43] In early 2003, the Ministry of Health announced the eight guiding principles for their targeted reforms, including universal health insurance, easily accessible and extensive healthcare, and strengthened primary and family care.[44] Between 2003 and 2010, the parliament and Council of Ministers issued a series of policy reforms that, inter alia, unified all health insurance schemes into a state single-payer under the Social Security Institution and launched the Family Medicine Program.[45]
The Law
To understand the legal mechanisms underpinning the Family Medicine Program, it is helpful to understand the general legal system in Türkiye. The Turkish legal system is best described as a civil law system in which its constitution and codified laws bear the greatest authority.[46] The government consists of executive, legislative, and judicial branches.[47]The executive power is vested in the President, directly elected by Turkish voters.[48] The President has the power to, inter alia, issue presidential decrees with the effect of law. However, such presidential decrees are void if they regulate fundamental individual liberties or political rights.[49] The legislative function is vested in the Grand National Assembly of Türkiye, which passes legislation that is enacted after the President’s approval.[50] International treaties also bear legal authority, as do administrative decrees by the Council of Ministers.[51]
As to the judiciary, the constitution creates the Turkish Supreme Courts, each of which is the highest authority for laws falling within its jurisdiction.[52] This essay centers on the Turkish Constitutional Court. Under Article 148 of the Turkish Constitution, the Constitutional Court is granted the authority to annul legislation it deems unconstitutional.[53]This power grants the Court authority in the health policymaking process. Notably, in 2006, the Court delayed the creation of the Social Security Institution by annulling specific provisions of the relevant legislation.[54] Conversely, in 1996, the Court annulled legislation restricting the length of health insurance coverage as a violation of the positive rights contained within the Turkish constitution.[55]
While Türkiye has a long and complex history of healthcare law and policy, four legal reforms were instrumental in enabling the Family Medicine Program. The first came in 1961 when the Grand National Assembly of Türkiye passed the Law on Socialization of Health Care Services.[56] Article 1 of the law declared that access to healthcare is recognized as a human right in Türkiye under the Universal Declaration on Human Rights, and “will be socialized within the framework of this law and so that these services can be utilized in a socially just manner.”[57] “Socialization” is defined in Article 2 as “the citizens’ [ability], through the premiums they pay and the budgets reserved in the public sector for health care service, [to] utilize all sorts of health care service free of charge or by paying a partial amount of the cost.”[58] The law also mandated the creation of state-run “health centers” for every 5,000 citizens with at least one physician, and “health posts” with a nurse and midwife for every 2,000 citizens.[59] However, due to inadequate funding and personnel willing to relocate to rural areas, the law’s mandate was not fulfilled until 1983.[60]
Notably, in 1982, the Turkish constitution was amended to contain an article guaranteeing a positive right to healthcare access.[61] Article 56 provides the following: “Everyone has the right to live in a healthy and balanced environment . . . The State shall regulate the central planning and functioning of the health services to ensure that everyone leads a healthy life physically and mentally and provide cooperation by saving and increasing productivity in human and material resources. The State shall fulfill this task by utilizing and supervising the health and social assistance institutions in both the public and private sectors. To establish widespread health services, general health insurance may be introduced by law.”[62] Article 56 incorporates the statutory definition of “healthcare services” found in the Law on Socialization of Health Care Services––“the extermination of factors harming human health and the protection of the public from such factors, treatment of patients, and rehabilitation of individuals with decreased physical and mental capacity.”[63]
In 1987, a political majority in the Turkish government sought to increase the role of the private sector in healthcare provision, believing that enacting neoliberal healthcare policies would address ongoing gaps in access to healthcare services.[64] To that end, the Basic Law on Health Services was passed, which – very broadly speaking – sought to limit the role of the Ministry of Health in healthcare service provision, transforming it into more of a healthcare regulator.[65]The opposition party challenged the constitutionality of the Law, arguing that it violated Article 56 by reducing the Ministry’s role in service provision, necessarily increasing the commercialization of healthcare provision to fill the gap.[66] In 1988, the Constitutional Court rejected the claim that Article 56 required healthcare services to be provided solely by the Ministry, simultaneously leaving its regulatory authority under the Law to set prices for healthcare services provided by public and private entities.[67] Although the Court ultimately annulled other provisions of the Law that left the government unable to implement it, the Ministry was statutorily empowered to regulate the cost of healthcare and continue providing services through health centers and posts.[68]
In 1992, the GNAT enacted the Green Card program to finance health care services for the indigent.[69] The program, funded by the Turkish Ministry of Health, provided free inpatient treatment for those who had no other health insurance coverage and made less than one-third of the minimum wage threshold.[70] Chronically ill individuals and seniors were also eligible for the program.[71] Moreover, the Green Card system was limited in reach. Beyond only covering inpatient services, it was not integrated into existing health insurance schemes and had no formal system for identifying beneficiaries.[72] It did, however, represent an essential step towards implementing the promise of Article 56 by codifying some basic healthcare access for all Turkish citizens.[73]
As previously discussed, launching the Health Transformation Programme in 2003 placed primary and preventive care at the heart of Türkiye’s efforts to achieve universal healthcare access. To that end, in 2005, the GNAT enacted the Law on the Pilot Implementation of Family Medicine.[74] The Law piloted the Family Medicine Programme in one province in Türkiye, replacing its existing health centers and posts with Family & Community Health Centers.[75] Gradually, the program expanded to all 81 provinces of Türkiye until ultimately every citizen was assigned a family physician.[76] The Ministry of Health now effectively acts as a healthcare service provider through the Family Medicine Program and a regulator under the Basic Law on Health Services.
Lessons
The Family Medicine Programme provides a few lessons for American policymakers interested in charting a path toward universal healthcare coverage. Perhaps most importantly, it illustrates that supply-side reform (i.e., the public provision of healthcare services) plays as crucial a role as demand-side reforms (i.e., public financing of privately provided healthcare services). Although Türkiye’s example demonstrates that laws can be passed to guarantee access to healthcare services, such laws do not immediately effectuate universal healthcare coverage. In the absence of more, laws do not build the infrastructure to support healthcare facilities or produce healthcare providers.
A discussion of law and policymaking can seem quaint in the reality of American political gridlock. It is hard to view the idea of comprehensive legislative reform as anything but theoretical when Congress has remained relatively unproductive and divided for virtually all of the 21st century.[77] However, the Family Medicine Programme can again serve as a lodestar in charting a path to actual change. Its legal and physical infrastructure had largely existed for most of the 20thcentury.[78] Rather than a comprehensive legislative package, a creative reevaluation of existing legal authorities and physical infrastructure is in order.
Professor Joey Fishkin of UCLA Law School has proposed a “Basic Health” model that calls to mind Türkiye’s Family Medicine Programme. Under his proposed Basic Health plan, the federal government would enroll every American in a “mini” health insurance plan that covers a short list of specific primary and preventative services (e.g., vaccinations, basic prenatal care, routine screenings) that offer universal benefit through strengthening public health and preventing costly hospitalizations.[79] Professor Fishkin’s rationale is that it is “relatively easy, politically and practically, to expand the coverage of a truly universal, popular, existing program.”[80]
The Family Medicine Programme demonstrates that it is quite possible – and arguably, more practical – for governments to achieve universal access to primary and preventative care by providing the care themselves rather than simply paying for care. In doing so, we could avoid the tremendous financial waste and administrative burden of the private insurance industry by obviating the need for reimbursement through direct service provision.
The U.S. already has a federal agency with the existing infrastructure and statutory authority to do this: the Department of Veterans’ Affairs (“VA”). The Department, created by Congress in 1921, consolidated veterans’ pension programs and was tasked with providing healthcare to World War I veterans.[81] What followed was an ambitious and sweeping construction project to create a federal government-run veterans’ hospitals across the country.[82] Over the decades since, this network has become America’s most extensive health care system, growing from 54 hospitals in 1930 to 1,600 healthcare facilities today (including 171 hospitals and 1,232 outpatient facilities).[83]
In 1982, the VA’s mission expanded. Congress passed the Health Resources Sharing and Emergency Operations Act, directing the VA to provide healthcare services to non-veterans in times of war, non-conflict related disasters, and where there are shortfalls in states.[84] The statute grants the VA authority to provide hospital care to non-veterans in response to federally declared disasters and emergencies.[85] Congress expanded the VA’s authority even further in 2001, passing a law authorizing the VA to provide hospital and medical services to non-veterans on a “humanitarian basis in emergency cases.”[86] The statute requires the VA to charge for such services, although the VA Secretary retains the sole authority to set reimbursement rates for services rendered.[87]
It is hard not to see the legal and institutional parallels between the VA and the Family Medicine Programme. Like in Türkiye, there is a broad, far-reaching state-run program focused on direct healthcare service provision. Like in Türkiye, previous recognition of ongoing gaps in healthcare coverage spurred legislative action granting authority to the federal government to directly provide certain healthcare services. Drawing upon the Family Medicine Programme and Professor Fishkin’s “Basic Health” proposal, I propose a pilot program for the federal provision of primary, preventative, and family healthcare services, launched at select VA medical facilities with the greatest need, ultimately expanding to all communities with a VA medical facility. The VA-led Basic Health Program could provide a range of primary, preventative, maternal, and emergency healthcare services—like those under the Family Medicine Programme—at little cost to patients.[88] The program could roll out, initially, at a limited number of VA medical facilities based on certain criteria, adjusted as necessary, and gradually expanded to encompass all regions of the U.S.[89]
Readers may be surprised to learn that policymakers have and continue to consider some version of this proposal. In 1989, VA Secretary Edward Derwinski, a “folksy Illinois Republican” appointed to his position by President George H.W. Bush, proposed opening certain rural VA hospitals to nonveterans who had no access to other medical facilities. However, his pilot program was abandoned due to veterans’ service organizations’ belief that it denigrated their benefits.[90] In 2020, VA hospitals opened their doors to nonveterans in response to the COVID-19 pandemic, providing 1,500 acute and intensive care beds in that year alone.[91] Former VA Assistant Secretary for Public and Intergovernmental Affairs Kayla Williams has called for Congress to explore ways for VA facilities underutilized by veteran patients to be opened to their local nonveteran communities.[92] In late 2021, the VA hospital in White River Junction, Vermont, opened their inpatient mental health services to civilians in response to a critical scarcity of such services in the community.[93]
Notably, drawing upon these experiences to provide public healthcare rather than paying for it would avoid the significant cost associated with publicly financed health insurance schemes. A Trump-era VA initiative to allow veterans to receive VA services directly or have the VA foot the bill for their private care has led to skyrocketing costs, with a single VA medical facility in the South reporting $54 million in spending on private care payment.[94] A similar program in the civilian sector, Medicare Advantage, has overhead costs nearly seven times that of traditional Medicare.[95]
Conclusion
While much of American healthcare policy discourse has centered on single-payer or not, there are significant points of reference both at home and abroad to suggest alternative options that achieve the same goals. Of course, comprehensive legislative reform of our healthcare financing and delivery is necessary. However, it is hard to suggest that millions of Americans should suffer inequitable health outcomes while policymakers develop the will and capital required to pass such legislation. This essay uses comparative analysis to spur creative reevaluation of existing legal tools and physical infrastructure to achieve more equitable health outcomes. The Family Medicine Programme, a resounding success evidenced by key health metrics, shows one way for the U.S. to do so. By implementing an initiative like the VA-led Basic Health proposal, the U.S. can efficiently use the tools it already has to efficiently begin meaningful steps towards universal healthcare access.
About the Author
Zach Outzen is a 2022 graduate of William & Mary Law School and a public interest attorney, providing pro bono legal assistance to veterans seeking disability benefits. While in law school, he interned at the Richmond Public Defender’s Office, Legal Services of Northern California, and the Air Force JAG Corps’ Special Victims’ Counsel. He also worked in the Lewis B. Puller, Jr. Veterans Benefits Clinic and served as the Symposium Editor for the William & Mary Environmental Law & Policy Review. Prior to law school, he graduated from Christopher Newport University with a B.A. in English. He is also a proud second-generation Turkish immigrant and family member to six U.S. Army veterans.
[1] See How Does Universal Health Care Coverage Work? Health System Features, The Commonwealth Fund, https://www.commonwealthfund.org/international-health-policy-center/system-features/how-does-universal-health-coverage-work (last visited Mar. 11, 2023).
[2] Press Release, The Commonwealth Fund, New International Study: U.S. Health System Ranks Last Among 11 Countries; Many Americans Struggle to Afford Care as Income Inequality Widens (Aug. 4, 2021), https://www.commonwealthfund.org/press-release/2021/new-international-study-us-health-system-ranks-last-among-11-countries-many.
[3] Id.
[4] Id.
[5] How Does the U.S. Healthcare System Compare to Other Countries?, Peter G. Peterson Found. (July 19, 2022), https://www.pgpf.org/blog/2022/07/how-does-the-us-healthcare-system-compare-to-other-countries.
[6] Id.
[7] Id.
[8] See David Goldhill, Opinion: In Health Care, America is the World’s Indispensable Nation, Wash. Post (Nov. 29, 2022, 7:00 AM), https://www.washingtonpost.com/opinions/2022/11/29/us-health-care-expensive-indispensable-nation/.
[9] Danielle Kurtzleben, Democratic Debate Exposes Deep Divides Among Candidates Over Health Care, Nat’l. Pub. Radio (Sep. 13, 2019, 12:37 AM), https://www.npr.org/2019/09/13/760364830/democratic-debate-exposes-deep-divides-among-candidates-over-health-care.
[10] Id.
[11] Jonathan Cohn, The ACA, Repeal, and the Politics of Backlash, Health Affs. (Mar. 6, 2020), https://www.healthaffairs.org/do/10.1377/forefront.20200305.771008.
[12] Id.
[13] Although this essay does not specifically address reproductive justice, it must be mentioned that the Supreme Court’s overturning of Roe v. Wade reflected this dynamic as well. See generally Dobbs v. Jackson Women’s Health Org., 597 U.S. __, 142 S. Ct. 2228 (2022). Abortion access remains deeply popular in the U.S., and Republicans paid a costly political price for engineering an unpopular policy change through litigation. See Hoag Levins, What the Surprising Midterm Results Mean for Health Care Policy, Penn. Leonard Davis Inst. (Nov. 14, 2022), https://ldi.upenn.edu/our-work/research-updates/what-the-surprising-midterm-results-mean-for-health-care-policy/.
[14] See id. (Discussing the Trump administration‘s rewriting of regulations about the kind of plans private insurers could sell through the marketplace); also Cynthia Cox et al., Five Things to Know About the Renewal of Extra Affordable Care Act Subsidies in the Inflation Reduction Act, Kaiser Fam. Found. (Aug. 11, 2022), https://www.kff.org/policy-watch/five-things-to-know-about-renewal-of-extra-affordable-care-act-subsidies-in-inflation-reduction-act/ (analyzing the impact of ACA subsidies enacted in the 2022 Inflation Reduction Act).
[15] This is to say nothing of the persistent neoliberal impulse to restrict subsidized healthcare for low-income individuals. It must be noted that the battle over access to Medicaid is still being litigated in the courts, with troubling implications. For the sake of brevity, this essay does not discuss the ongoing attacks on Medicaid, although I encourage readers passionate about health justice to learn more about the issue. See generally Our Cases, Nat‘l Health L. Program, https://healthlaw.org/our-cases (last visited Mar. 11, 2023).
[16] Frank Pasquale, The Epicycles of Health Care Market Design: Time for a Paradigm Shift in Health Policy, L. & Pol. Econ. Project (Nov. 27, 2017), https://lpeproject.org/blog/the-epicycles-of-health-care-market-design-time-for-a-paradigm-shift-in-health-policy/.
[17] Id.
[18] Id.
[19] Id.
[20] Id.
[21] Country Policy and Information Note––Turkey: Medical and Healthcare Provision, U.K. Home Off. Indep. Advisory Grp. 8-9 (2021), https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/979377/CPIN_-_Turkey_-_Medical_and_healthcare._FINAL._APRIL_2021.pdf.
[22] Tatar et al., Turkey: Health System Review, 13 Health Sys. in Transition xiii (2011), https://www.euro.who.int/__data/assets/pdf_file/0006/158883/e96441.pdf.
[23] Resul Cesur et al., The Value of Socialized Medicine: The Impact of Universal Primary Healthcare Provision on Mortality Rates in Turkey 4 (Nat’l Bureau of Econ. Rsch., Working Paper No. 21510, 2015, rev. 2017), https://www.nber.org/system/files/working_papers/w21510/w21510.pdf.
[24] Id.
[25] Gürkan Sert & Sefik Görkey, Turkey, in International Encyclopaedia of Laws: Medical Law 38 (Herman Nys ed., 2023).
[26] Rifat Atun et al., Universal Health Coverage in Turkey: Enhancement of Equity, 382 Lancet 65, 76 (2013), https://doi.org/10.1016/S0140-6736(13)61051-X.
[27] Id. at 79.
[28] Id. at 72.
[29] Id. at 92.
[30] Global Health Expenditure Database, World Health Org.,https://apps.who.int/nha/database/country_profile/Index/en (Compare “Türkiye” with “United States of America”) (last updated Mar. 11, 2023).
[31] Cesur et al., supra note 23, at 6.
[32] Atun et al., supra note 26, at 67; Maternal Mortality Ratio from 2000-2017 (Modeled Estimate, Per 100,000 Live Births), World Bank, https://data.worldbank.org/indicator/SH.STA.MMRT?end=2017&most_recent_value_desc=true&start=2010 (search “Turkïye”) [hereinafter “Maternal Mortality Ratio”].
[33] Maternal Mortality Ratio, supra note 32.
[34] Tatar et al., supra note 22, at xiii.
[35] Origins of the NHS, U.K. Nat’l Archives, https://www.nationalarchives.gov.uk/cabinetpapers/alevelstudies/origins-nhs.htm (last visited Mar. 11, 2023).
[36] Alex Blumberg and Adam Davidson, Accidents of History Created U.S. Health System, Nat’l Pub. Radio (Oct. 22, 2009, 3:28 PM), https://www.npr.org/2009/10/22/114045132/accidents-of-history-created-u-s-health-system.
[37] Rifat Atun, Transforming Turkey’s Health System – Lessons for Universal Coverage, 373 New Eng. J. Med. 1285, 1285 (2015), https://rmhs.ku.edu.tr/wp-content/uploads/2016/07/nejm_2015_turkey.pdf; Nurşen Aydin, Historical Perspective on the Health Transformation in Turkey, 12 Sağlık Bilimlerinde Değer 188, 189 (2022), https://dergipark.org.tr/tr/download/article-file/2183451.
[38] See infra Section 2.
[39] Aydin, supra note 37, at 189.
[40] Atun, supra note 37 at 1285.
[41] Atun, supra note 37, at 1285; Aydin, supra note 37, at 189.
[42] Atun, supra note 37, at 1285.
[43] Atun et al., supra note 26, at 71.
[44] History of the Ministry of Health, Turk. Ministry of Health, https://web.archive.org/web/20221022003059/https://www.saglik.gov.tr/EN,15601/history.html (last updated June 2, 2018).
[45] Atun, supra note 37, at 1285.
[46] Nihan Bacanak et al., Legal Systems in Turkey: Overview, Thomson Reuters Prac. L., W-016-2851, https://uk.practicallaw.thomsonreuters.com/w-016-2851?transitionType=Default&contextData=(sc.Default)&firstPage=true – co_anchor_a444405 (last updated Oct. 1, 2022) (see responses to questions 9 and 10).
[47] Id. (see responses to questions 2 and 3).
[48] Turk. Const., art. 104 (available at: https://www.constituteproject.org/constitution/Turkey_2017.pdf?lang=en).
[49] Id.
[50] Turk. Const., art. 89 (available at: https://www.constituteproject.org/constitution/Turkey_2017.pdf?lang=en).
[51] See Serap Yazıcı, Update: A Guide to Turkish Public Law and Research, N.Y.U. Hauser Glob. L. Sch. Program, at 9.4 (2017), https://www.nyulawglobal.org/globalex/Turkey1.html#_International_Treaties. Prior to 2017, the Turkish system was parliamentary, with a Prime Minister and Council of Ministers were responsible for implementing legislation. See id. at 6.3. However, in the wake of a failed coup d’état in 2016, President Recep Tayyip Erdogan spearheaded the passage of constitutional amendments that abolished the Prime Minister and their Council, consolidating much of their power within the Presidency and transforming the parliamentary system into a strong presidential government. See Alan Makovsky, Ctr. for Am. Progress, Erdoğan’s Proposal for an Empowered Presidency 1 (Mar. 22, 2017), https://www.americanprogress.org/wp-content/uploads/2017/03/TurkeyProposedPresidential-report.pdf.
[52] Yazıcı, supra note 51, at 7.1.
[53] Id.; see also Turk. Const., art. 148 (available at: https://www.constituteproject.org/constitution/Turkey_2017.pdf?lang=en).
[54] Tatar et al., supra note 22, at 149.
[55] Halit Yılmaz, Realizing Social and Economic Rights: The Example of Judicial Attitudes Towards The Rationing of Healthcare in Turkey, 6 Haccetepe HFD 47, 55 (2016), http://www.hukukdergi.hacettepe.edu.tr/dergi/C6S1makale2.pdf.
[56] Sert & Görkey, supra note 25, at 34.
[57] Id.
[58] Id.
[59] Tatar et al., supra note 22, at 18.
[60] Id.; Volkan Yılmaz, Health Reform and New Politics of Health Care in Turkey, Univ. Leeds Sch. Pol. & Int’l Stud., at 59 (2014), https://etheses.whiterose.ac.uk/7635/1/PhD%20Thesis_Submitted%20Version_21.12.2014.pdf.
[61] Atun, supra note 37, at 1285.
[62] Turk. Const., art. 56 (available at: https://www.constituteproject.org/constitution/Turkey_2017.pdf?lang=en).
[63] Sert & Görkey, supra note 25, at 39-40.
[64] Volkan Yılmaz, supra note 60, at 71.
[65] Atun et al., supra note 26, at 69.
[66] Volkan Yılmaz, supra note 60, at 71-72.
[67] Id.; Aydin, supra note 37, at 189.
[68] Aydin, supra note 37, at 189.
[69] Rekha Menon et al., Toward Universal Coverage: Turkey’s Green Card Program for the Poor, 18 World Bank UNICO Stud. Series, at 7 (2013), https://openknowledge.worldbank.org/server/api/core/bitstreams/fd3b9be5-1893-5bb6-a873-7d37b9a6aaa6/content; Volkan Yılmaz, supra note 60, at 73.
[70] Menon et al., supra note 69, at 7.
[71] Id.
[72] Atun, supra note 37, at 1285.
[73] Volkan Yılmaz, supra note 60, at 73-74.
[74] Sert & Görkey, supra note 25, at 28.
[75] Id.
[76]. Cesur et al., supra note 23, at 11.
[77] Sarah Binder, Going Nowhere: A Gridlocked Congress, Brookings Inst. (Dec. 1, 2000), https://www.brookings.edu/articles/going-nowhere-a-gridlocked-congress/ (describing how “gridlock is endemic to [American] politics”); Lee Drutman, How Much Longer Can This Era of Political Gridlock Last?, FiveThirtyEight (Mar. 4, 2021), https://fivethirtyeight.com/features/how-much-longer-can-this-era-of-political-gridlock-last/ (concluding that analysis shows “more divided government is probably imminent, and the electoral pattern we’ve become all too familiar with — a pendulum swinging back and forth between unified control of government and divided government — is doomed to repeat . . . ”); see supra text accompanying ACA notes re: limits to comprehensive healthcare reform (describing political incentives inherent in significant healthcare policy shifts).
[78] See discussion accompanying law on socialization.
[79] Joseph Fishkin, The Case for Basic Health, L. & Pol. Econ. Project (Nov. 22, 2019), https://lpeproject.org/blog/the-case-for-basic-health/.
[80] Id.
[81] VA History, U.S. Dep’t of Veterans Affrs., https://www.va.gov/HISTORY/VA_History/Overview.asp (last updated May 27, 2021).
[82] Id.
[83] Id.; Veterans Health Administration, U.S. Dep’t. of Veterans Affrs., https://www.va.gov/health/ (last updated Dec. 28, 2022).
[84] Gupta et al., Finding the Rainbow in the Storm: VA Care for Non-veterans with COVID-19, U. of Mich. Health Lab(June 07, 2021), https://labblog.uofmhealth.org/rounds/finding-rainbow-storm-va-care-for-non-veterans-covid-19; VHA Office of Emergency Management: Fourth Mission, U.S. Dep‘t. of Veterans Affrs., https://www.va.gov/VHAEMERGENCYMANAGEMENT/4thMission.asp (last updated May 6, 2021).
[85] 38 U.S.C. § 1785.
[86] Department of Veterans Affairs Health Care Programs Enhancement Act of 2001, Pub. L. No. 107-135, 115 Stat. 2446 (codified as 38 U.S.C. § 1784).
[87] Id.
[88] While these services would ideally be provided at no cost to the patient, 38 U.S.C. § 1784 requires the VA to charge a fee for services provided to nonveterans on a “humanitarian” basis. To preserve the universality of the program, the VA could employ either a sliding scale model determining fees based on a patient’s income or could charge a nominal fee of only a few dollars.
[89] Recent history provides examples of how the pilot medical facility locations could be selected. A 2018 law mandated a VA Asset & Infrastructure Review Commission (“AIR Commission”) to consider VA recommendations for facility closure or sale to private hospitals and real estate groups. See Suzanne Gordon et al., Our Veterans: Winners, Losers, Friends, and Enemies on the New Terrain of Veterans Affairs 229-30 (2022). The makeup of the AIR Commission had a “preordained private-sector tilt,” with specific seats reserved for private-sector representatives. Id. Ultimately, the VA presented its recommendations to the Commission. However, they were never advanced by the Commission, as sustained advocacy by veterans and labor unions led a bipartisan group of Senators to block the Commission from being formed. See Press Release, Am. Fed. of Gov. Emps., Largest Federal Employee Union Applauds Senate Plan to Block VA Closure Commission (June 27, 2022), https://www.afge.org/publication/largest-federal-employee-union-applauds-senate-plan-to-block-closure-commission/; Everett Kelley, By Blocking AIR Commission, Congress Ensures Veterans Get the Best Care, The Hill (July 8, 2022), https://thehill.com/opinion/congress-blog/3550684-by-blocking-air-commission-congress-ensures-veterans-get-the-best-care/. Crucially, the VA developed its recommendations by estimating current and future usage of VA facilities. See VA Recommendations to the Asset & Infrastructure Review Commission, Volume I: Introduction, Approach, Methodology, and Outcomes, U.S. Dep’t of Veterans Affs. 30-31 (2022), https://www.va.gov/AIRCOMMISSIONREPORT/docs/VA-Report-to-AIR-Commission-Volume-I.pdf. Ironically, these recommendations would serve the VA Basic Health pilot program well. Underutilized facilities recommended for closure by the AIR Commission could instead be the first to open to nonveterans, preserving the physical infrastructure while meeting the needs of underserved populations. For a list of VA medical facilities that would have been closed by the Commission, see AIR Commission Medical Center Closures, Am. Fed. of Gov. Emps. (2022),https://www.afge.org/common-pages/save-my-va/air-commission-medical-center-closures/.
[90] T. Rees Shapiro, Edward J. Derwinski, First Secretary of the Department of Veterans Affairs, Dies, Wash. Post (Jan. 18, 2012), https://www.washingtonpost.com/politics/congress/edward-j-derwinski-first-secretary-of-the-department-of-veterans-affairs-dies/2012/01/18/gIQA5IlL9P_story.html.
[91] See Gupta et al., supra note 84.
[92] Gordon et al., supra note 89, at 232.
[93] Id. at 233-34.
[94] Id. at 165; Patricia Kime, VA Weighs Limiting Access to Outside Doctors to Curb Rising Costs, Mil. (June 15, 2022), https://www.military.com/daily-news/2022/06/15/va-weighs-limiting-access-outside-doctors-curb-rising-costs.html.
[95] See Gordon et al., supra note 89, at 227.
*Source of featured image: Bernard Marr, The 9 Biggest Technology Trends That Will Transform Medicine and Healthcare in 2020, Forbes (Nov. 1, 2019, 2:26 AM), https://www.forbes.com/sites/bernardmarr/2019/11/01/the-9-biggest-technology-trends-that-will-transform-medicine-and-healthcare-in-2020/?sh=639c22a572cd.