The US Congress passed the Health Care Reform Bill on March 21, 2010 after a long debate. The then President Barack Obama signed it as a historic achievement and said, "After a century of efforts, health insurance reform is being enacted in the United States today."

The law, known as 'Obama Care', increased the role of the state and brought coverage to millions of uninsured citizens who did not have access to health care. Republicans opposed it as excessive state intervention, and President Donald Trump unsuccessfully tried to replace it during his first term. As a result, the health policy controversy flared up. This context illustrates the socio-political complexity of health care. However, there is little we can learn from the US health care system.

In the last decade, Nepal has made significant progress in vaccination campaigns, improvement of maternal and child health, control of communicable diseases and expansion of basic health services. After 2046, private investment has contributed to the expansion and improvement of the quality of health services, but the access of the lower class is limited due to expensive treatment.

Despite being called a socialist-oriented state system, the health system is becoming more complicated due to the commercialization of the health sector and the influence of the private sector in policy making. Due to the lack of services in remote areas, the inability of the poor to afford treatment, changing lifestyles, problems such as cancer and heart disease are increasing, and the treatment is becoming more expensive and it is also difficult to get healthcare easily. 

In such a situation, the National Health Insurance Program launched in 2072 to ensure access to health of the citizens was praised from all over. This program, which will be managed by the Health Insurance Board, was started in Kailali and has now been implemented in all 77 districts. Under this program, per family (up to 5 people) can get services up to a maximum of 1 lakh rupees by paying 3,500 per year. This service is available in 482 hospitals and health institutions.

The main economic principles of health insurance are risk pooling and risk aversion. Under risk sharing, many people collectively share health expenses by paying insurance premiums, which reduces financial risk. Because of risk aversion, people want to buy insurance to avoid uncertain future health expenses. Most of the health systems that are considered successful around the world have mandatory insurance, universal access, quality services, adequate financial security and effective health infrastructure and human resources. 

dr. Ezekiel J. In his book 'Which country's health care is the best in the world?', Emanuel said that Germany's health system is one of the best among developed countries. Among the few low-income countries, Rwanda has managed to provide accessible healthcare to nearly 90 percent of its population. Despite limited financial resources, Cuba's health care is also discussed as one of the best, as it provides free health care to the public, emphasizing primary health care and effective preventive measures. 

As suggested in Dani Rodrik's book 'One Economics, Many Recipes', although the economic-political principles of the health sector are the same, for successful implementation strategies should be adopted according to the specific economic, political and social conditions of each country.

If we look at the experience of our health insurance, it is not possible to pay on time, because the service is provided only by limited health institutions, it has not reached the general public. On the one hand, the insurance renewal rate is Rs. From 75 in 2077/78, it has dropped to 53 percent in 2079/80. The outstanding amount to be paid has exceeded 15 billion.

According to ADB's study on health insurance in Nepal, since insurance is not mandatory, only about 21 percent of people are insured, most of whom are patients, and about 40 percent of the insured have taken treatment services. This has increased the financial risk of the government. On the other hand, due to the fact that services are provided only by limited health institutions, patients have to travel long distances, stay in transport, hotels, lodges and have to face many difficulties in the referral process.

The Minister of Health was highly praised when he talked about increasing the scope of health insurance to five lakhs without considering the condition of our resources. But after understanding the actual situation, the same minister has started criticizing the same minister after saying that payment is not possible and this program may be closed. 

Currently, many health institutions across the country have suspended insurance programs due to payment issues. Some are in the process of being postponed. Due to poor management and inability to assess the complexity of health insurance, there is a suspicion that this national health insurance program, implemented with good intentions, may fail within a decade. However, it has not reached the level where it cannot be improved.

Mandatory government health insurance and integration of all other treatment facilities programs under social security into one system can also improve it. In addition to making health services accessible, according to the principle of risk sharing, individual contributions will decrease and the government's health expenses will be reduced, as well as unnecessary administrative hassles and costs. 

As we have in some successful health systems, supplementary private insurance can be arranged at no more than 10 percent, which will reduce public expenditure and give individuals some freedom of choice in health care. However, it is necessary to pay attention to making government universal health insurance compulsory for private insurance takers and not allowing the private sector to dominate. 

In countries that have adopted a successful universal health care model, insurance funds are managed efficiently through employers, workers, governments and international cooperation. For example, the Sickness Fund in Germany is administered by the Federal Insurance Authority, while the Social Security Board in Rwanda administers the Mutuel de Sante. 

This need has been realized in the proposal for a new draft on safe insurance put forward by our health minister. The plan to divide the citizens into four categories such as salary earners, tax payers, those who can pay premiums and those who cannot is theoretically correct, but the practical challenge must be solved. It is difficult to clearly distinguish these categories mainly due to lack of necessary data. If we have to rely on the assessment of the ward office, many citizens may fall into the group who cannot pay the premium, which may put a huge financial burden on the state. 

4.6 percent of the amount allocated to the health sector in the last budget is very less compared to countries with universal health care systems. From this, it is easy to understand that our health sector is not a priority. In a country like ours with limited formal employment and closed trade, the role of the state in insurance funding remains paramount. On the one hand, financial resources are shrinking due to decline in foreign aid and reduction in domestic tax collection, and on the other hand, unnecessary spending cuts have become imperative when misuse of public finances is increasing. We can learn from the successful experiences of Australia, Norway and Sri Lanka to control drug prices. An effective first aid strategy could work in Rwanda, Sri Lanka and Cuba. 

The insured person may use unnecessary services or adopt an unhealthy lifestyle, thinking that the insurance will pay during the treatment, patients and health workers may not become thrifty, which is called moral hazard. To reduce this, measures such as implementing co-payments (copays) and deductibles (deductibles), increasing health awareness and engaging celebrities to encourage healthy lifestyles can be effective.