The ongoing ideological fight over whether the United States should ensure that all Americans have health care coverage came to a head last week with the US Supreme Court’s decision to uphold the Affordable Care Act. While that decision rested on technical grounds – the Court ruled that the states and individuals bringing the challenge did not have legal standing to force a decision on the legal merits – it was widely viewed as a victory for the ACA law itself.
The Affordable Care Act – often called “Obamacare” – has now been law for a decade and has fundamentally changed health care delivery in the nation. At the same time, the ACA has helped expand health insurance coverage to those most in need – individuals whose incomes were too high to obtain Medicaid coverage (health coverage for the poor and needy), yet too young to obtain coverage from Medicare (the universal health insurance system for those over the age of 65).
The morally reprehensible position of trying to take away health coverage from those covered by the ACA was made clear as the COVID-19 pandemic swept the nation. Recklessly putting partisan and ideological interests ahead of the health of Americans is simply indefensible in normal times and particularly odious during a pandemic.
Simply put, lacking health insurance can be a death sentence.
Yet, the USA stands in stark contrast to the world’s developed nations. All other wealthy nations have universal health coverage, although they organize their systems differently. England, for example, has a national health service (NHS) that provides health care to all its residents. Its government owns the hospitals and providers of NHS care, including ambulance services, mental health services, district nursing, and other community services. Germany, on the other hand, has a more decentralized system, one that allows roles for its regional governments and a highly regulated private sector.
In all cases, however, the cost of health care delivery is less expensive than in America, and the life-expectancy in all these nations exceeds that of the USA. The United States spends 17 percent of its Gross National Product on health care (pre-pandemic) yet ranks 28th of the 37 Organisation for Economic Co-operation and Development (OECD) member nations in life expectancy.
In short, citizens in those countries pay less and get more than Americans when it comes to health care.
That’s not to say that other nations’ health systems uniformly perform better that the American system – COVID vaccine rollouts have taken far more time outside of the US (and China).
Nevertheless, the Supreme Court’s decision should open a national debate over how best to proceed. Assuming universal coverage is the goal, the United States still has a long way to go. While the ACA expanded coverage to 20+ million Americans, nearly 30 million still lack health insurance of some form.
Vermont’s Senator Sanders is leading an effort in the Senate to include health coverage in the next round of the Congress’s budget reconciliation. The Senator is pushing for changes that include a lowering of the age of Medicare eligibility from 65 to 60 and providing expanded coverage for those on Medicare – such as dental coverage. Whether Sanders’s efforts will succeed is unclear, but that doesn’t mean that states should sit back.
The Affordable Care Act used the state of Massachusetts’s health insurance system as its model. That plan, advanced during the tenure of Republican Governor Mitt Romney, required residents to get insurance, expanded Medicaid coverage to those whose incomes were close to – but not below – the poverty line, and offered government-organized health coverage with state subsidies for those middle-income residents who did not qualify for other programs or whose employers did not offer coverage.
Massachusetts now has near-universal coverage. Over the past decade, New York State set up its own program and has seen a dramatic reduction in its uninsured.
But there are still an estimated one million New Yorkers who lack coverage, with one quarter million lacking coverage due to their immigration status. Given the fiscal limitations of expanding coverage – the state has been looking for ways to spend less on Medicaid for example – any expansion should be coupled with ways to rein-in costs.
One proposal with widespread legislative support (known as NY Health), is for New York to reorganize its health coverage system to squeeze out insurance industry costs and use those savings to fund a robust program of coverage.
Amid the worst acute public health crisis in generations, the current insurance system failed massively. People lost their health insurance. Hospitals and providers, operating with just-in-time systems and investments oriented to expensive treatments rather than public health, were less well equipped to absorb the pandemic demands than they should have been. Ensuring coverage for all is one critical way that New York – and the nation – can help people who are sick, can reduce costs, and extend lifespans. Those are benefits worthy of serious debate at both the federal and state levels.