The United States is the only industrial country that does not provide universal health coverage for its citizens. In fact many much poorer countries (e.g., Cuba and Thailand) do so also. The result is a healthcare system that is of lower quality and inequitable. What is stopping our government from giving Americans universal health coverage? Why aren’t Americans demanding it?
One of the main goals of Obamacare (PPACA) was to extend health insurance coverage to the uninsured through the creation of the Health Insurance Marketplace (also called the Exchanges) and through the expansion of Medicaid. These schemes were supposed to take America on a path toward universal health coverage. Unfortunately, trying to build universal health coverage onto a fragmented, inefficient healthcare system where the needs of moneyed special-interests come before the needs of the public welfare is doomed to failure. The inefficiencies and high costs of healthcare were allowed to perpetuate and fester. Our government does not have a clear healthcare policy for converting our healthcare system into one that serves the needs of the general public over the needs of special-interests who profit from it. As we Americans wait for the promised Republican-led repeal of Obamacare (PPACA), I find myself pondering if true universal health coverage for the public welfare will finally be on offer. Let’s look at what universal coverage actually means.
What is Universal Health Coverage?
Universal health coverage is not “socialized” medicine. In a universal healthcare system, all citizens or residents of a particular country are provided with a specific package of health benefits for the delivery of “financial risk protection, improved access to health services, and improved health outcomes”. The benefits package should be geared toward maximizing the health of all citizens or residents subject to budget constraints. The universal benefits package will not cover every health service and product that the medical community has to offer, especially those that are not cost-effective or are of questionable health benefit. If our government has a $2 trillion health budget, then leaders armed with healthcare data would determine what products and services achieve maximal benefit? In the United States today, taxpayer-subsidized health benefit packages include those provided by Medicare, Medicaid, Veterans Health, Obamacare (PPACA) Essential Health Benefits, and many, many employer-sponsored health plans.
I believe that our government has the responsibility to ensure that all healthcare providers deliver quality healthcare that is cost-effective, equitable, and efficient. All healthcare policy should put the needs of the individual Americans first. Promoting and protecting health is essential to human welfare and sustained economic and social development. A person who is sick, but cannot afford to get medical care will be a drain on our economy. I also believe that our government is responsible for ensuring that everyone can access the universal health benefits they need and that everyone is protected from the financial risks associated with using them. A universal healthcare system will deliver these basic human rights.
The three aspects of universal health coverage include (1) who is covered, (2) what services are covered, and (3) how much of the cost is covered. All universal health systems pay for healthcare services from pooled funds (i.e., funds that are accumulated before illness occurs).
In the figure above, the aspects of universal health coverage do not take into account how the various members of HICUP (BB Brigade acronym for those who are engaged in the business of health care in the USA) are affected financially. In defining universal health benefits, the needs of individual Americans take center stage. The economic benefits from an efficient universal health system will “trickle down” to all parts of our economy.
Financing Universal Health Coverage
In the United States today, healthcare is financed largely through individual taxation, employer taxation, insurance premiums, and direct payments (cost-share) at the time of service. These funds are NOT presently accumulated into one risk pool for efficient distribution. There are three critical areas that need to be addressed when setting up financing for universal healthcare—raising sufficient funds, reducing financial risk to individuals, and ensuring maximum use of health resources (see figure below).
The biggest barrier to universal healthcare in the United States is not the lack of money to pay for it, but rather a existence of a healthcare system that divides Americans into many subgroups (both public and private) with different benefits packages and different taxpayer-subsidy structures. Our prepaid healthcare dollars are accumulated in many inefficiently administered insurance risk pools and our healthcare system relies heavily on direct payments at the time of service (i.e., cost-share). Experience in other nations shows that universal health coverage works best when health care costs are prepaid by a large number of people (i.e., large risk pool). Contributions also need to be compulsory (i.e., mandated) or the rich and healthy will opt out and there will be insufficient funds to cover health care for the sick and poor.
The obligation to pay directly for services at the moment of need prevents millions of people receiving health care when they need it. For those who do seek treatment, it can result in severe financial hardship, even impoverishment. The trend in the United States has unfortunately been to increase cost-share through high-deductible health plans rather than to reduce health spending by improving healthcare system inefficiencies.
All decisions for financing universal health coverage must take into account what is best for the people of the United States while maximizing the use of health resources and minimizing healthcare costs. The United States can no longer afford to foolishly spend more than double the amount spent by other high-income countries in our quest to enrich the various members of the healthcare and insurance communities at the expense of the rest of the economy.
Universal Health Coverage—Why Not?
While the benefits of universal health coverage are overwhelmingly obvious, Americans have been brainwashed to think of healthcare coverage as something that only some Americans deserve to have. Americans subdivide into social and racial groups and look out for their individual group benefits only. The young and healthy do not want to “pay” for the health care of the “old and sickly”. When Californians wanted some of the same taxpayer-subsidized health benefits as Veterans, various Veterans groups lobbied to keep these exclusive rights for themselves. The poor are reviled by many middle and upper-income Americans for being poor and call for a reduction in their Medicaid health benefits. Poor Americans are denied access to the most effective types of contraception for reasons that have nothing to do with what is good for the public health and the result is an increase in birth rate and higher healthcare costs.
What will it take for Americans to realize that universal health coverage benefits ALL of us, individually and as a country? Don’t let yet another government administration craft healthcare reform legislation that is written for the financial benefits of the healthcare industry. It is high time for universal health coverage that benefits the individual American citizen first and foremost! Contact your elected officials and demand that the Obamacare (PPACA) healthcare reform replacement be one that is universal.
Health Systems Financing The path to universal coverage, World Health Organization, 2010