“The arc of the health care universe is long, but it bends toward universal health coverage”

Thirteen years ago, as a student in New York City, I marched across the Brooklyn Bridge to implore my colleagues to fight for universal health care. That day, I enunciated what has become my personal mission by saying, “We need universal coverage that is portable. We need universal coverage that is comprehensive. We need universal coverage that ensures equal access to care. Most importantly, we need you. Our people need you. Our communities need you…to lead the fight, to force the issue, to bring to America a universal health care system where everybody is in, and nobody is left out.”

America needs universal health care. And universal health care needs physicians to lead the charge. But, universal health care means many things to many people. I can only tell you what my vision of universal health care looks like. But to adequately do that, I’ll need to tell you how I arrived at that vision. And to do that, it helps to know how countries across the world got there. Two of the greatest explanations come from T.R. Reid and Atul Gawande

First, T.R. Reid. His book “The Healing of America” explored the health systems around the world, placing them into one of 4 categories:

  • Beveridge model
  • National Health Insurance model
  • Bismarck model
  • Out of pocket model

The Beveridge model is essentially true “socialized medicine” where both the financing and delivery of health care happens in the public sector. Think of the UK’s National Health Service or the Veterans’ Health Administration, Indian Health Service, or military health systems in the U.S. 

The National Health Insurance (NHI) model is what many people think of as a traditional single payer system. Canada runs an NHI model; so does the U.S. Medicare program. The financing is public, but the delivery of services remains private. The NHI model is not “socialized medicine,” per se, rather “social insurance” where a nation agrees that everyone pays into a broad-based tax system so that those who require health care can have access to it. 

Another “system”, the out of pocket one, is merely a voluntary system of health coverage such as was the standard for Americans prior to the Affordable Care Act (ACA). As of this new year, with the repeal of the individual mandate, the U.S. again has a voluntary or out-of-pocket system.

The Bismarck model derives from late 19thcentury Germany and employs private health care delivery and often private financing (from employers and workers) wrapped around strict government regulations in a well-coordinated the system. France, Switzerland, and HealthCare.Gov fit this model. In fact, the Bismarck model is what conservatives in the U.S. rallied around in the 1990s as a potential model for the nation.

Around the same time that T.R. Reid was working on his book, Atul Gawande wrote an excellent piece for The New Yorker entitled “Getting There from Here” which explained why each of these countries has the health care system it has. It’s a concept called path dependence. So while Britain got the NHS, and Canada got single payer, we got stuck with employer sponsored health insurance (ESHI) as our major health care financing vehicle. 

The World War II era wage freezes that the federal government instituted, forbidding salary increases but allowing for fringe benefits like health care, aided the growth of ESHI. While being stuck with ESHI isn’t a horrible thing, it just doesn’t make sense if you want people outside the work force to also have health coverage. So, over time, the U.S. provided coverage to elderly people with Medicare and to poor people with Medicaid. So that’s the (relatively) quick history of how we arrived at a fragmented health care system where almost half the country gets covered by employers, about 15% Medicare, approximately 17% Medicaid, and a the rest either buy coverage on their own or go without. 

Despite the amount of attention it receives, the ACA only directly covers 7-10% of Americans (in a combination of the Medicaid expansion and the individual Marketplaces). Meanwhile, about 10% of the population remains uninsured. So how do we tackle that number?

Whenever I think about how we can move our health care system from where we are to where we want to be, i.e.universal coverage, I consider a few critical questions.

  • What does it mean to be “universal”?
  • Who is eligible?
  • How comprehensive do we want the coverage to be?
  • How do we pay for it?

When polled to determine what percentage of the population would have to be covered to count as “universal,” folks really want it to be 100%. Now, I’m a bit less idealistic when it comes to universal health care. My pragmatic nature suggests that 100% is too difficult to achieve even if it is a laudable goal. Eighty-four percent of poll respondents said that at least 98% coverage was good enough. There is one thing to point out, however,uninsured, undocumented immigrants are just under 2% of the U.S. population. If we covered everyone else (excluding only that group) we could meet that 98% coverage goal. Ultimately, that becomes a political choice.

The definition of what percentage of the population must be covered to be considered “universal” dovetails into who becomes eligible for coverage. If we choose to exclude undocumented immigrants from coverage, relegating that population to care in public hospitals, but keep them in the population denominator, we affect both the eligibility question and the “universal” question. Again a political decision, who is covered will require adequate and explicit deliberation if we are to know what universal health carewill mean in America.

Comprehensiveness directly impacts how much “we” (i.e.the taxpayer or family) have to pay for coverage. John Graves from Vanderbilt illustrates this issue. A figure he create begs the question, what do people mean when they say Medicare for All?  Specifically, which actuarial value? Medicare, as it currently exists, pays for about 76% of a patient’s anticipated health care costs. That is roughly equivalent to a high deductible employer plan. “Expanded & Improved Medicare for All” would cover nearly 100% of a patient’s anticipated expenses which for all intents and purposes is the equivalent to today’s Medicaid plans for children. Do advocates instead mean a plan equivalent to employer coverage? If so, the comprehensiveness – in terms of actuarial value – is closer to 80-84%. Comprehensiveness of care is something that digs deep into our moral values while simultaneously extracting a price from our collective wallets. Therefore, it becomes yet one more thing we, as a society, must consider carefully. 

Is it feasible to expect someone making the average American income or, worse yet, someone below the poverty line to pay for 25% of their health care tab? Is it fair that someone who makes over six figures pay nothing for their health care other than the taxes used to fund the system?

In my view, if an American universal health care plan is going to have a lower actuarial value  – similar to the current Medicare or something close to an ESHI package – we must have some kind of protection for the poor and the sick to prevent them from avoiding necessary health care due to cost.

Lastly, the finances are where the rubber hits the road. Paying for universal health carehas one of two problems – the math and the politics. It’s easy to figure out how much all of health care spending would be and imagining funding it via a lump sum. The question is, who wants to pay that sum?

The think tank Mercatus recently released an analysis on Medicarefor All. The headlines screamed that it would cost $33T over a decade. That seems like a large sum of money until you consider that all that money is already INSIDE the current health care system. Americans are just paying for that care in a thousand different ways. So with single payer you can cover 30 million more people with less money than we currently spend. The math is EASY. But the politics is HARD.

I suspect, you won’t find a universal health coverage solution for America where both the MATH and the POLITICS are easy. We’re a nation of people who, in general, hate paying taxes. We lack the social solidarity seen by Europeans. And right now, the men & women who make our laws can’t even seem to play nice.

I used to think a Swiss style system would be best (see my KevinMD post on that subject). Unfortunately the current GOP is a bit stuck on denying that Obamacare was even their (and the Heritage Foundation’s) idea so don’t expect cooperation from them. So until there is a House of Representatives controlled by Democrats, 60 Senate Democrats, and a willing President, I doubt single payer will come to fruition. 

My suggestion: keep the ESHI system for people that want it and provide Medicare for everyone else. We could fold all those other federal and state health programs into Medicare, fold in the currently uninsured, and create a system that leaves no one out, except those who opt to keep employer coverage.

Ultimately, the people that are in the workforce and pay taxes will have to decide to carry everyone else’s burden, so that others – children, the poor, the elderly, the sick – can afford to see a doctor. But, until Americans demonstrate they are explicitly willing to do that, I will continue sit back and ruminate on this: “The arc of the health care universe is long, but it bends toward universal health coverage.”