essays against universal healthcare

Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons

Every citizen of every country in the world should be provided with free and high-quality medical services. Health care is a fundamental need for every human, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal health care is the provision of healthcare services by a government to all its citizens (insurancespecialists.com). This means each citizen can access medical services of standard quality. In the United States, about 25% of its citizens are provided with healthcare funded by the government. These citizens mainly comprise the elderly, the armed forces personnel, and the poor (insurancespecialists.com).

Introduction

Thesis statement.

• Universal Healthcare Pros
• Universal Healthcare Cons

Works Cited

In Russia, Canada, and some South American and European countries, the governments provide universal healthcare programs to all citizens. In the United States, the segments of society which do not receive health care services provided by the government usually pay for their health care coverage. This has emerged as a challenge, especially for middle-class citizens. Therefore, the universal health care provision in the United States is debatable: some support it, and some oppose it. This assignment is a discussion of the topic. It starts with a thesis statement, then discusses the advantages of universal health care provision, its disadvantages, and a conclusion, which restates the thesis and the argument behind it.

The government of the United States of America should provide universal health care services to its citizens because health care is a basic necessity to every citizen, regardless of age, gender, ethnicity, religion, and socioeconomic status.

Universal Healthcare Provision Pros

The provision of universal health care services would ensure that doctors and all medical practitioners focus their attention only on treating the patients, unlike in the current system, where doctors and medical practitioners sped a lot of time pursuing issues of health care insurance for their patients, which is sometimes associated with malpractice and violation of medical ethics especially in cases where the patient is unable to adequately pay for his or her health care bills (balancedpolitics.org).

The provision of universal health care services would also make health care service provision in the United States more efficient and effective. In the current system in which each citizen pays for his or her health care, there is a lot of inefficiency, brought about by the bureaucratic nature of the public health care sector (balancedpolitics.org).

Universal health care would also promote preventive health care, which is crucial in reducing deaths as well as illness deterioration. The current health care system in the United States is prohibitive of preventive health care, which makes many citizens to wait until their illness reach critical conditions due to the high costs of going for general medical check-ups. The cost of treating patients with advanced illnesses is not only expensive to the patients and the government but also leads to deaths which are preventable (balancedpolitics.org).

The provision of universal health care services would be a worthy undertaking, especially due to the increased number of uninsured citizens, which currently stands at about 45 million (balancedpolitics.org).

The provision of universal health care services would therefore promote access to health care services to as many citizens as possible, which would reduce suffering and deaths of citizens who cannot cater for their health insurance. As I mentioned in the thesis, health care is a basic necessity to all citizens and therefore providing health care services to all would reduce inequality in the service access.

Universal health care would also come at a time when health care has become seemingly unaffordable for many middle income level citizens and business men in the United States. This has created a nation of inequality, which is unfair because every citizen pays tax, which should be used by the government to provide affordable basic services like health care. It should be mentioned here that the primary role of any government is to protect its citizens, among other things, from illness and disease (Shi and Singh 188).

Lastly not the least, the provision of universal health care in the United States would work for the benefit of the country and especially the doctors because it would create a centralized information centre, with database of all cases of illnesses, diseases and their occurrence and frequency. This would make it easier to diagnose patients, especially to identify any new strain of a disease, which would further help in coming up with adequate medication for such new illness or disease (balancedpolitics.org).

Universal Healthcare Provision Cons

One argument against the provision of universal health care in the United States is that such a policy would require enormous spending in terms of taxes to cater for the services in a universal manner. Since health care does not generate extra revenue, it would mean that the government would either be forced to cut budgetary allocations for other crucial sectors of general public concern like defense and education, or increase the taxes levied on the citizens, thus becoming an extra burden to the same citizens (balancedpolitics.org).

Another argument against the provision of universal health care services is that health care provision is a complex undertaking, involving varying interests, likes and preferences.

The argument that providing universal health care would do away with the bureaucratic inefficiency does not seem to be realistic because centralizing the health care sector would actually increase the bureaucracy, leading to further inefficiencies, especially due to the enormous number of clientele to be served. Furthermore, it would lead to lose of business for the insurance providers as well as the private health care practitioners, majority of whom serve the middle income citizens (balancedpolitics.org).

Arguably, the debate for the provision of universal health care can be seen as addressing a problem which is either not present, or negligible. This is because there are adequate options for each citizen to access health care services. Apart from the government hospitals, the private hospitals funded by non-governmental organizations provide health care to those citizens who are not under any medical cover (balancedpolitics.org).

Universal health care provision would lead to corruption and rent seeking behavior among policy makers. Since the services would be for all, and may sometimes be limited, corruption may set in making the medical practitioners even more corrupt than they are because of increased demand of the services. This may further lead to deterioration of the very health care sector the policy would be aiming at boosting through such a policy.

The provision of universal health care would limit the freedom of the US citizens to choose which health care program is best for them. It is important to underscore that the United States, being a capitalist economy is composed of people of varying financial abilities.

The provision of universal health care would therefore lower the patients’ flexibility in terms of how, when and where to access health care services and why. This is because such a policy would throw many private practitioners out of business, thus forcing virtually all citizens to fit in the governments’ health care program, which may not be good for everyone (Niles 293).

Lastly not the least, the provision of universal health care would be unfair to those citizens who live healthy lifestyles so as to avoid lifestyle diseases like obesity and lung cancer, which are very common in America. Many of the people suffering from obesity suffer due to their negligence or ignorance of health care advice provided by the government and other health care providers. Such a policy would therefore seem to unfairly punish those citizens who practice good health lifestyles, at the expense of the ignorant (Niles 293).

After discussing the pros and cons of universal health care provision in the United States, I restate my thesis that “The government of United States of America should provide universal health care to its citizens because health care is a basic necessity to every citizen, regardless of age, sex, race, religion, and socio economic status”, and argue that even though there are arguments against the provision of universal health care, such arguments, though valid, are not based on the guiding principle of that health care is a basic necessity to all citizens of the United States.

The arguments are also based on capitalistic way of thinking, which is not sensitive to the plight of many citizens who are not able to pay for their insurance health care cover.

The idea of providing universal health care to Americans would therefore save many deaths and unnecessary suffering by many citizens. Equally important to mention is the fact that such a policy may be described as a win win policy both for the rich and the poor or middle class citizens because it would not in any way negatively affect the rich, because as long as they have money, they would still be able to customize their health care through the employment family or personal doctors as the poor and the middle class go for the universal health care services.

Balanced politics. “Should the Government Provide Free Universal Health Care for All Americans?” Balanced politics: universal health . Web. Balanced politics.org. 8 august https://www.balancedpolitics.org/universal_health_care.htm

Insurance specialists. “Growing Support for Universal Health Care”. Insurance information portal. Web. Insurance specialists.com 8 august 2011. https://insurancespecialists.com/

Niles, Nancy. Basics of the U.S. Health Care System . Sudbury, MA: Jones & Bartlett Learning, 2010:293. Print.

Shi, Leiyu and Singh, Douglas. Delivering Health Care in America: A Systems Approach . Sudbury, MA: Jones & Bartlett Learning, 2004:188. Print.

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IvyPanda. (2023, February 18). Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/

"Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." IvyPanda , 18 Feb. 2023, ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

IvyPanda . (2023) 'Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons'. 18 February.

IvyPanda . 2023. "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." February 18, 2023. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

1. IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." February 18, 2023. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

Bibliography

IvyPanda . "Healthcare Thesis Statement: Examples of Universal Healthcare Pros and Cons." February 18, 2023. https://ivypanda.com/essays/pros-and-cons-of-universal-health-care-provision-in-the-united-states/.

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Why doctors have stood against universal health care — and why that could be changing

A younger generation of doctors are more likely to advocate for single-payer health care, writes Dr. Clifford Marks.

Many in this country struggle to understand their health care plan, and feel they don’t have much agency in choosing it. The United States has a patchwork of plans that contributes to more spending on health care than any other developed nation. And yet, many influential and powerful people advocate against single-payer health care.

For many years, the American Medical Association has been that kind of institution as it helped wreck former President Harry Truman’s 1950s universal health care bill that otherwise had majority support from Americans. But in recent years, the association has been showing signs that it may be changing its tune .

“When you have to slog through pre-authorizations, suddenly single-payer healthcare, I think, seems a lot more appealing.” —Dr. Clifford Marks, Mount Sinai Hospital in New York

Listen: Why the American Medical Association may be more open to supporting single-payer health insurance.

Dr. Clifford Marks is an emergency-medicine resident at Mount Sinai Hospital in New York. He recently wrote a piece in The New Yorker about a younger generation of doctors that are advocating for universal health care coverage.

He says younger physicians have to contest with large industries, including pharmaceutical companies, hospital systems and insurance systems, which are all difficult to navigate.

“When you have to slog through pre-authorizations, suddenly single-payer health care, I think, seems a lot more appealing,” says Marks.

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Towards Universal Health Care in Emerging Economies pp 61–88 Cite as

Universalism and Health: The Battle of Ideas

• Susanne MacGregor 2  
• First Online: 02 March 2017

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Part of the book series: Social Policy in a Development Context ((SPDC))

In this chapter, MacGregor contextualizes the issue of universal health coverage. She summarizes moves towards the adoption of universal health coverage as a goal of international policy. Arguments for universal health coverage are reviewed, noting references to human rights, social justice, security and social integration. Competing ideas are considered—universalism versus selectivism, welfare state versus neoliberalism and social investment. The chapter looks at the political mobilization of ideas in high-income and middle-income countries. Issues of implementation, variations in financing mechanisms and state capacity are noted. The conclusion is that politics matters—even more so as new challenges appear.

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MacGregor, S. (2017). Universalism and Health: The Battle of Ideas. In: Yi, I. (eds) Towards Universal Health Care in Emerging Economies. Social Policy in a Development Context. Palgrave Macmillan, London. https://doi.org/10.1057/978-1-137-53377-7_3

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Why the US does not have universal health care, while many other countries do

Assistant Professor, Texas A&M University Health Science Center, Texas A&M University

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The lead-up to the House passage of the American Health Care Act (AHCA) on May 4, which passed by a narrow majority after a failed first attempt, provided a glimpse into just how difficult it is to gain consensus on health care coverage.

In the aftermath of the House vote, many people have asked: Why are politicians struggling to find consensus on the AHCA instead of pursuing universal coverage? After all, most advanced industrialized countries have universal health care.

As a health policy and politics scholar, I have some ideas. Research from political science and health services points to three explanations.

No. 1: American culture is unique

One key reason is the unique political culture in America. As a nation that began on the back of immigrants with an entrepreneurial spirit and without a feudal system to ingrain a rigid social structure, Americans are more likely to be individualistic .

In other words, Americans, and conservatives in particular, have a strong belief in classical liberalism and the idea that the government should play a limited role in society. Given that universal coverage inherently clashes with this belief in individualism and limited government, it is perhaps not surprising that it has never been enacted in America even as it has been enacted elsewhere.

Public opinion certainly supports this idea. Survey research conducted by the International Social Survey Program has found that a lower percentage of Americans believe health care for the sick is a government responsibility than individuals in other advanced countries like Canada, the U.K., Germany or Sweden.

No. 2: Interest groups don’t want it

Even as American political culture helps to explain the health care debate in America, culture is far from the only reason America lacks universal coverage. Another factor that has limited debate about national health insurance is the role of interest groups in influencing the political process. The legislative battle over the content of the ACA, for example, generated US$1.2 billion in lobbying in 2009 alone.

The insurance industry was a key player in this process, spending over $100 million to help shape the ACA and keep private insurers, as opposed to the government, as the key cog in American health care.

While recent reports suggest strong opposition from interest groups to the AHCA, it is worth noting that even when confronted with a bill that many organized interests view as bad policy, universal health care has not been brought up as an alternative.

No. 3: Entitlement programs are hard in general to enact

A third reason America lacks universal health coverage and that House Republicans struggled to pass their plan even in a very conservative House chamber is that America’s political institutions make it difficult for massive entitlement programs to be enacted. As policy experts have pointed out in studies of the U.S. health system, the country doesn’t “have a comprehensive national health insurance system because American political institutions are structurally biased against this kind of comprehensive reform.”

The political system is prone to inertia, and any attempt at comprehensive reform must pass through the obstacle course of congressional committees, budget estimates, conference committees, amendments and a potential veto while opponents of reform publicly bash the bill.

Bottom line: Universal coverage unlikely to happen

Ultimately, the United States remains one of the only advanced industrialized nations without a comprehensive national health insurance system and with little prospect for one developing under President Trump or even subsequent presidents because of the many ways America is exceptional.

Its culture is unusually individualistic, favoring personal over government responsibility; lobbyists are particularly active, spending billions to ensure that private insurers maintain their status in the health system; and our institutions are designed in a manner that limits major social policy changes from happening.

As long as the reasons above remain, there is little reason to expect universal coverage in America anytime soon.

Editor’s note: this is an updated version of an article that originally ran on October 25, 2016.

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• 18 May 2021

Universal health care must be a priority — even amid COVID

You have full access to this article via your institution.

The COVID pandemic illustrated how a lack of reliable health care renders communities vulnerable. Credit: John Moore/Getty

Vaccinating the world’s population against COVID-19 remains a global health priority. But it is vital that this effort does not overshadow the need to ensure that everyone, everywhere has access to basic health care.

Despite the urgency of the current crisis, the provision of universal health care remains a priority for Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization (WHO). It is also enshrined in the United Nations Sustainable Development Goals on the basis that health is a prerequisite for economic growth. Governments, scientists and the public should support this goal, because it’s in everyone’s best interests. And they will have an opportunity next week, when the World Health Assembly convenes online.

The pandemic has amply demonstrated how a lack of reliable health care can render communities vulnerable. Although access to health care isn’t the sole factor that determined how well countries fared, its absence clearly fuelled the flames. Many lives have been lost in India because hospitals have been overwhelmed. In the United States, COVID-19 deaths have been higher among people on low incomes, who are less likely to have health insurance and therefore less likely to seek medical care promptly. A similar pattern has been seen elsewhere: one study found that in the poorer neighbourhoods of Santiago, more than 90% of people whose deaths were attributed to COVID-19 died outside health-care facilities ( G. E. Mena et al. Science https://doi.org/f9b4; 2021 ). Moreover, people without reliable health care might be more vulnerable to complications of COVID-19 because of poorly controlled chronic diseases.

Will COVID force public health to confront America’s epic inequality?

A lack of easily accessible health care — and of health systems for sharing information — has impeded the detection and monitoring of COVID-19 infections. Should another deadly virus emerge in a region with inadequate health care, the world could lose valuable time to contain the outbreak. The two largest Ebola outbreaks so far — in West Africa and the Democratic Republic of the Congo — spread for weeks to months before they were identified.

Despite almost a century of calls to provide all people with health care, attempts have been stymied by crises and disease-specific interventions. After the economic depression of the 1930s, international health officials working for the League of Nations touted the need for the provision of basic health services by country-wide networks of clinics. This vision was interrupted by the Second World War, but was revived in 1946, when the newly formed United Nations met to write a constitution for the WHO. The constitution stated that health is a human right, and that governments are responsible for the health of their people.

But the United States nearly rejected the WHO and its constitution outright. At the time, opponents of national health-care provision in the country connected the measure to socialism and communism. The United States eventually signed on, but inserted a clause stating that it could withdraw from the WHO at any time — meaning that the country donating the most money (dues are based on the size of economies) could walk away if it opposed the organization’s ideology.

How to defuse malaria’s ticking time bomb

The next 20 years of single-disease programmes driven by the WHO and global health funders wasn’t ideological, however. Ironically, they were also driven by a wave of scientific advances that offered simple, technological fixes to specific health problems, such as the use of the insecticide DDT to fight malaria and antibiotics to fight infections.

But, in 1978, the push to build up health systems was revived at an international conference on providing everyone with primary health care, held in Alma-Ata in what was then the Soviet Union. The resulting WHO-sponsored Alma-Ata declaration vowed to provide essential care, at the level of neighbourhoods, by the year 2000.

But according to Tedros and health-policy experts, the Alma-Ata declaration was undermined by factors including inadequate political leadership, economic crises, political instability and an over-investment in treating individual diseases ( T. A. Ghebreyesus et al. Lancet 392 , 1371–1372; 2018 ). Others have suggested that the movement lacked defined steps backed by evidence, as well as cost-effectiveness assessments. Compare this with the UN children’s charity, UNICEF, which in the 1980s vowed to save the lives of four million to five million children a year through well-defined and budgeted programmes to deliver vaccines for diseases including measles, tetanus and polio. Government and philanthropic donors grasped the concept immediately, and UNICEF quickly became one of the larger UN agencies. In 2019, its budget was nearly three times that of the WHO.

Childhood immunization programmes save lives, but the lack of investment in strengthening countries’ health systems has led to untold deaths. The answer isn’t to stop vaccinations, of course, but to take cues from the success of UNICEF’s campaign and the failures of Alma-Ata.

Why did the world’s pandemic warning system fail when COVID hit?

In 2019, the WHO once again turned the focus on health care for all, this time at the first UN high-level meeting on universal health care. A corresponding report stated that to provide all people with primary health care, countries, on average, must increase their spending in this area by 1% of their gross domestic product. And world leaders signed a declaration promising to pursue universal health care — in their national context — and provide basic, affordable health services to everyone in the country. To hold them accountable, global-health researchers have created an online portal to track progress towards the attainment of this goal by 2030. For example, the tracker says that about 15% of the populations of the United States and Cuba lack access to essential health services. The rate grows to 20% in China and 45% in India and Kenya.

The WHO has placed ‘health for all’ high on the agenda of next week’s meeting, hoping to drive political and financial commitments from governments. Perhaps mindful of the vagueness that doomed past efforts, Tedros has created a new council of economists, health and development experts to advise on the economics of providing everyone with basic health care, including ways to quantify its value.

Universal health care might seem a lofty goal amid a crisis, but if we do not push for change now, we will regret it. The pandemic has increased the number of people living in extreme poverty, making them more vulnerable to disease. It’s infected, killed and traumatized health-care workers everywhere, most devastatingly in places that had too few already. “Our failure to invest in health systems doesn’t only leave individuals, families and communities at risk, it also leaves the world vulnerable to outbreaks and other health emergencies,” Tedros said in October 2019. “A pandemic could bring economies and nations to their knees.” A few months later, it did. We must not let that happen again.

Nature 593 , 313-314 (2021)

doi: https://doi.org/10.1038/d41586-021-01313-3

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"Healthcare for All"?: The Gap Between Rhetoric and Reality in the Affordable Care Act

Introduction.

According to its proponents, the passage of the Affordable Care Act (ACA) 1 “enshrined . . . the core principle that everybody should have some basic security when it comes to their health care.” 2   However, the ACA does not ensure healthcare coverage for many groups.  Indeed, projections indicate that 27 million uninsured Americans will remain even after enactment of all of the ACA ’s provisions. 3   Most sizeable among these groups are certain classes of noncitizens, including but not limited to undocumented immigrants.

Why does the statutory reality differ from the lofty, expansive language used by the ACA ’s proponents in Congress and the White House, especially with respect to noncitizens?  A parsing of the ACA ’s legislative history, particularly the congressional floor debates over the bill, reveals two possible answers.  Both answers are instructive to advocates hoping to extend access to health insurance coverage to all noncitizen groups.  First, at least some legislators implicitly qualify the notion of healthcare for all with the requirement that beneficiaries of the law must pay taxes  Second, at least some legislators seem to exclude certain noncitizen groups from their definition of “Americans,” which is used interchangeably with the terms “everybody” or “all” throughout the legislative history of the ACA .

Part I of this Essay examines the ACA ’s statutory and accompanying regulatory language, identifying three noncitizen groups that receive reduced or no protections under the law: (1) recently arrived legal immigrants; (2) noncitizens present under temporary nonimmigrant visas, known as nonim­migrants; and (3) undocumented immigrants.  Part II explores the legislative history of the ACA and the idealistic statements repeatedly made by legislators about the idea of healthcare for all.  It identifies similar statements made by proponents of previous versions of healthcare reform during prior presidential administrations, suggesting a historical pattern of disconnect.

Part III concludes that implicit normative and economic arguments legislators made against the expansion of healthcare coverage to these excluded groups, particularly the undocumented, offer a partial explanation for the gap between the rhetoric and reality of the ACA .  It also critiques these arguments and offers suggestions to advocates for expanded healthcare coverage in overcoming these implicit arguments against true healthcare for all.

I. The Affordable Care Act and Exclusion of Certain Noncitizen Groups

This Part distills a general outline of the ACA ’s contours before analyzing how recent legal immigrants, legal nonimmigrants, and undocumented immi­grants are not protected under the new legislation.  The ACA is both voluminous and complex, clocking in at nearly 1000 pages and containing various provisions that will not go into effect until later this decade. 4   Multiple constitutional and political challenges to the ACA , the most significant of which the U.S. Supreme Court resolved only in June of 2012, 5 slowed down the states’ implementation of the bill. 6   Further, the U.S. Department of Health and Human Services is still promulgating regulations in accordance with the statute’s decrees more than two years after the bill’s passage. 7   All of this uncertainty over the ACA makes it difficult to analyze the ACA with a high degree of specificity.  However, even a general summary of the law demonstrates the notable absence of the three groups identified above from all of the ACA benefits.

A. General Outline of the ACA

B. reduced protections for recently arrived legal immigrants, c. reduced protections for legal nonimmigrants.

The ACA also fails to offer full protections to the nearly two million nonimmigrant residents in the United States. 32   Nonimmigrants, who are present in the country on temporary visas and include university students, skilled and unskilled laborers recruited by U.S. employers, and family members of U.S. citizens or lawful permanent residents, 33 are often a forgotten group. 34   Yet many of these individuals lawfully reside in this country for up to several years.  Many of them undoubtedly require access to healthcare at some point during their time here.

D. Reduced Protections for Undocumented Immigrants

Finally, the estimated eleven million undocumented immigrants in this country 40 are specifically excluded from virtually all of the ACA ’s protections  As one commentator summarizes:

II. Legislative History of and Rhetoric Surrounding the Affordable Care Act

The ACA deliberately refrained from extending full access to healthcare for recently arrived LPRs and nonimmigrants.  The ACA also excluded undocu­mented immigrants from all, or virtually all, of its protections.  Yet, as this Part demonstrates, the ACA ’s statutory realities appear to belie the expansive language used by the ACA ’s advocates, who repeatedly defended the idea of healthcare access to “everyone” or “all Americans” in the sponsor statements, floor debates, and signing statements associated with the bill. 47   This trend is a continuation of history, as policymakers who pushed previous iterations of healthcare reform during previous presidential administrations also employed universal language in publicizing their efforts.  Yet policymakers did not include groups like the undocumented in their policy proposals.  The result is an apparent, longstanding tension between the ideas of healthcare for all and healthcare for noncitizens.

A. The Legislative History of the ACA

Representative Louise Slaughter’s seemingly contradictory statements are indicative of this paradox.  Representative Slaughter called up the bill for a vote and in her remarks stated:

The legislative history of the bill is less clear, however, about the reasons for offering diminished protection to newly arrived LPRs and nonimmigrants.  Only one congressman made a floor statement about the plight of newly arrived legal immigrants under the bill.  Representative Honda lamented that the bill did not “lift the 5 year bar on legal immigrant participation in Medicaid.  Legal immigrants are tax paying [sic] citizens in waiting who work hard and contribute.  It is only fair that we afford them equal access to the benefits of Medicaid.” 58   Meanwhile, no floor statements, committee reports, or other statements made by lawmakers suggested that legislators were preoccupied by the fate of nonimmigrants under the bill.

Finally, after the bill passed both Congressional houses and landed on President Obama’s desk on March 23, 2010, the president also used expansive, even universal, language when referring to the beneficiaries of the ACA :

B. History of Healthcare Reform Advocacy in America

The ACA was an unprecedented overhaul of our nation’s healthcare system.  It was the product of decades of advocacy for expanded access to healthcare for Americans that germinated in Theodore Roosevelt’s presidential administration nearly a century ago. 60   As healthcare costs and the number of uninsured in the United States continued to balloon, the political will to reform the system strengthened.  And just like with the ACA , the idea that “all Americans” deserved access to healthcare animated the political discourse through Republican and Democratic presidencies alike in the last hundred years, though the concrete proposals failed to extend protection to all noncitizen groups.  The ACA ’s repetition of history may be instructive in understanding why legislators persist in leaving out certain noncitizens from their conception of universal healthcare.

The rhetoric past legislators and policy advocates used to push for such legislation also centered around the notion that “all Americans deserve healthcare.”  For example, Mrs. Clinton and other advocates of her plan 1993 Health Care Reform Plan made such statements as “If we do not have universal coverage . . . we do not have health care reform.” 65   And yet, past iterations of healthcare expansion legislation, such as the 1993 plan, did not cover undocumented immigrants beyond already existing emergency Medicaid protections in the event of immediate and severe health crises. 66   In the past, as in the present, a gap existed between the ideals that animated the push for healthcare reform and the substance of the proposals ultimately put forth with respect to noncitizen groups like the undocumented.

III. Implicit Rationale for the Gap Between Reality and Rhetoric: The Definition of “American”

It is, of course, impossible to definitively explain how the entire 111th U.S. Congress rationalized the exclusion of the three noncitizen groups identified above.  Parsing the legislative history—particularly the floor debates—reveals implicit economic and normative social assumptions legislators made about the role of undocumented immigrants in particular.  Perhaps these assumptions explain, at least in part, the inconsistencies in the statutory language of and legislative history about the ACA explored in this Article.  This Part explores these potential economic and social rationales, critiques them, and offers ways for healthcare reform advocates to overcome them.

A. Concerns About Economic Freeridership

Most of the comments made by legislators concerned the potential for undocumented immigrants to benefit from the ACA are economic in nature.  Time and time again, legislators opposed to the bill mentioned the fear that undocumented immigrants would benefit from free healthcare at the (presumably legally present) taxpayers’ expense 67 and “open[] the floodgates” to millions more of the undocumented who would further burden our welfare system. 68   News reports suggest the floodgates argument also partially explains why legislators declined to lift the Medicaid residency and immigrant status requirements in the ACA for legal immigrants and nonimmigrants. 69   A plausible way this fear qualifies the seemingly unconditional healthcare for all is the idea that legislators actually mean healthcare for all who pay into the system.

Second, the floodgates argument is also specious.  The number of legal immigrants and nonimmigrants would not increase with expanded access to Medicaid because the United States has caps on the number of immigrants and nonimmigrants who may enter the country each year. 74   Further, many immi­gration analysts argue that undocumented are primarily motivated to enter this country due to the presence of brighter economic opportunities, especially in the unskilled and low-skilled sectors, where the supply of U.S. citizen workers is low. 75   Whether healthcare benefits are available is ancillary when compared to whether upward social and economic mobility is possible through available jobs. 76   The decrease in the number of undocumented immigrants during the past four years 77 as the American economy underwent a recession and a slow recovery 78 supports this view of immigration.

Finally, some studies have shown that giving all individuals access to preventative and nonemergency healthcare is ultimately more cost-effective for the nation as a whole. 79   In support of this point, it is worthwhile to note that the undocumented population is generally younger and healthier than the American population as a whole, 80 and adding them into insurance risk pools may lower premiums and costs of emergency healthcare for all. 81   It is true that other studies claim that the federal government may not gain money from subsidizing so many Americans’ health insurance. 82   It is impossible, however to deny the longterm gains in economic productivity and reduction in emergency room and emergency Medicaid costs that would result if all people—including recently arrived LPRs, nonimmigrants and the undocumented—had health insurance. 83   The possibility of realizing such gains would seem to merit seriously considering expanding undocumented immigrants’ rights to access healthcare.

Perhaps most who opposed the ACA covering undocumented immigrants generally oppose the concept of the ACA .  It is true that those who mentioned the potential economic burdens that undocumented immigrants would create by receiving benefits under the ACA were opposed to the ACA as a whole on other grounds.  This includes the idea that the ACA was too redistributivist. 84   This counterargument, however, fails to explain why those who supported the ACA and the idea that wealthy taxpayers pay more taxes for all less wealthy Americans’ health insurance also supported excluding the noncitizen groups identified above from the bill.

If indeed some legislators were motivated to deny undocumented immi­grants, recently arrived LPRs, and nonimmigrants access to full healthcare benefits under the ACA because of economic concerns, those who advocate for expanded healthcare coverage for these three noncitizen groups may do well to make two primary economic arguments supporting coverage.  First, these groups, particularly the undocumented, contribute to federal tax revenue.  Second, the national economy and federal government would benefit from an expansion of coverage for all three groups.

B. Healthcare as a Privilege of Citizenship

Another solution to overcoming legislators’ exclusive definition of “American” is to expand the definition of “American” in the political discourse to include the noncitizen groups in question.  This task would be no less Herculean, as it requires changing long-held views on the role of immigrants in the United States. 106   This effort, however, would have the added benefits of staving off the desire of some legislators to oppose CIR efforts if and when that mantle is again taken up by public officials and of preventing legislators from potentially limiting the benefits to which newly legalized immigrants are entitled.

A close examination of the ACA ’s legislative history suggests two possibly interrelated ways that legislators reconciled the competing concepts of universal healthcare and fewer healthcare protections for noncitizens in crafting the ACA .  Perhaps understanding these rationales will allow healthcare advocates on behalf of noncitizens to redouble their efforts to obtain equal access to healthcare for recently arrived legal immigrants, nonimmigrants, and the undocumented.

Despite the rhetoric of universal healthcare and healthcare for all that pervaded the healthcare debate, the ACA does not fully protect certain legal immigrants or nonimmigrants and fails to protect the undocumented at all, leaving millions of Americans still without access to health insurance.  The legislative history of the ACA suggests that legislators’ biases towards these noncitizen groups, particularly with respect to the economic impact of insuring them and the idea that they are not “American,” may explain this gap.  Advocates for universal healthcare must combat these biases, push for comprehensive immigration reform, or, preferably, employ both strategies in order for rhetoric to meet reality in the concept of healthcare for all.

• For the purposes of this Essay, the ACA also refers to the Health Care and Education Reconciliation Act of 2010, which was passed a week later to amend portions of the Patient Protection and Affordable Care Act.  See Pub. L. No. 111-152, 124 Stat. 1029 (2010). ↩
• Joe Biden & Barack Obama, Remarks by the President and Vice President at Signing of the Health Insurance Reform Bill (Mar. 23, 2010), available at http://www.whitehouse.gov/the-press-office/remarks-president-and-vice-president-signing-health-insurance-reform-bill . ↩
• How the Number of Uninsured May Change With and Without the Health Care Law , N.Y. Times , June 27, 2012, http://www.nytimes.com/interactive/2012/06/27/us/how-the-number-of-uninsured- may-change-with-and-without-the-health-care-law.html . ↩
• U.S. Dep’t of Health & Human Serv., Key Features of the Affordable Care Act by Year , Healthcare.gov , http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html (last visited June 30, 2013). ↩
• Adam Liptak, Justices, by 5–4, Uphold Health Care Law; Roberts in Majority; Victory for Obama , N.Y. Times , June 29, 2012, at A1. ↩
• Abby Goodnough & Robert Pear, With Obama Re-elected, States Scramble Over Health Law , N.Y. Times, Nov. 8, 2012, http://www.nytimes.com/2012/11/09/health/states-face-tight-health-care-deadlines.html . ↩
• See, e.g. , Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Small Business Health Options Program, 78 Fed. Reg. 33,233 (June 4, 2013) (to be codified at 45 C.F.R. pts. 155–156). ↩
• Health Care Reform Tops Obama’s Priority List , PBS NewsHour (June 8, 2009, 12:30 PM), http://www.pbs.org/newshour/updates/health/jan-june09/healthpreview_06-08.html . ↩
• Shailagh Murray & Lori Montgomery, House Democrats Pull Together on Health Care , Wash. Post , Oct. 30, 2009, http://www.washingtonpost.com/wp-dyn/content/article/2009/10/29/AR2009102901841_pf.html . ↩
• Sheryl Gay Stolberg & Robert Pear, Obama Signs Health Care Overhaul Bill, With a Flourish , N.Y. Times , Mar. 23, 2010, http://www.nytimes.com/2010/03/24/health/policy/24health.html . ↩
• See id. ↩
• Allison K. Hoffman, Three Models of Health Insurance: The Conceptual Pluralism of the Patient Protection and Affordable Care Act , 159 U. Pa. L. Rev. 1873, 1915–16 (2011). ↩
• See Liptak, supra note 5. ↩
• Robert Pear & Abby Goodnough, States Decline to Set Up Exchanges for Insurance , N.Y. Times , Nov. 17, 2012, at A14 . ↩
• Originally, state-run exchanges were slated to begin running on January 1, 2014; however, delays have ensued due to constitutional uncertainty surrounding the Act and recalcitrance on the part of some states.  The federal government will run exchanges in any states that are unwilling or unable to run their own exchanges.  Id. ↩
• Hoffman, supra note 12, at 1916–17. ↩
• Id . at 1916 . ↩
• Id. at 1920. ↩
• See Robert Pear, Uncertainty Over States and Medicaid Expansion , N.Y. Times , June 29, 2012, at A16 . ↩
• Liptak, supra note 5. ↩
• John Elwood, What Did the Court “Hold” About the Commerce Clause and Medicaid? , Volokh Conspiracy (July 2, 2012, 11:28 AM), http://www.volokh.com/2012/07/02/what-did-the-court-hold-about-the-commerce-clause-and-medicaid .  States may now choose whether to expand Medicaid coverage without incurring a loss of federal Medicaid funding if they choose not to expand.  Pear, supra note 19.  If they do choose to expand, they may seek the ACA ’s additional funding for the expansion.  Id. ↩
• Id. ↩
• Karla Guerrero, Waiting Five Years for Healthcare: How Restricting Immigrants’ Access to Medicaid Harms All , 21 Annals Health L. Advance Directive 109, 113 (2011). ↩
• Id. at 112–13. ↩
• Ruth Ellen Wasem, Cong. Research Serv., Noncitizen Eligibility for Federal Public Assistance: Policy Overview and Trends 4 (2012). ↩
• Guerrero, supra note 23, at 115 (“Emergency Medicaid covers the costs of emergency medical treatment through the Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, which requires hospitals to treat individuals facing medical emergencies regardless of their ability to pay, their immigration status, or whether the hospital could receive reimbursement for services that went beyond simply stabilizing the patient’s medical emergency.”). ↩
• See Mee Moua et al., Immigrant Health: Legal Tools/Legal Barriers , 30 J.L. Med. & Ethics 189, 192 (2002). ↩
• Alison Siskin, Cong. Research Serv., Treatment of Noncitizens Under the Patient Protection and Affordable Care Act 4 (2011). ↩
• Guerrero, supra note 23, at 115–16 (footnote omitted). ↩
• Michelle Nicole Diamond, Legal Triage for Healthcare Reform: The Conflict Between the ACA and EMTALA , 43 Colum. Hum. Rts. L. Rev. 255, 298–99 (2011); see also Tim Rutten, Op-Ed., Immigration Reform and the Healthcare Debate , L.A. Times , Jan. 9, 2010, http://articles.latimes.com/2010/jan/09/opinion/la-oe-rutten9-2010jan09 (explaining how Los Angeles–area hospitals would be disproportionately impacted by cuts to the emergency medical treatment program). ↩
• Emily Deruy, Healthcare Overhaul Would Cause Longer Emergency Room Lines for Some Immigrants , ABC News (Sept. 25, 2012), http://abcnews.go.com/ABC_Univision/Politics/longer-emergency-room-lines-undocumented-immigrants-affordible-care/story?id=17321383 . ↩
• Michael Hoefer et al., Office of Immigration Statistics, Estimates of the Unauthorized Immigrant Population Residing in the United States: January 2011 , at 4 (2012). ↩
• See Justin Hess, Comment, Nonimmigrants, Equal Protection, and the Supremacy Clause , 2010 B.Y.U. L. Rev. 2277, 2278. ↩
• Id. at 2287. ↩
• See, e.g. , Ill. Health Matters, Immigrants and the ACA : A Primer 1, http://illinoishealthmatters.org/wp-content/uploads/2012/09/Immigrants-and-the-ACA-1.pdf (last visited June 30, 2013); see also Nathan Cortez, Embracing the New Geography of Health Care: A Novel Way to Cover Those Left out of Health Reform , 84 S. Cal. L. Rev. 859, 889 (2011). ↩
• Nat’l Immigration Law Ctr., “Lawfully Present” Individuals Eligible Under the Affordable Care Act 1, 6 (2012), www.nilc.org/document.html?id=809. ↩
• Siskin , supra note 28, at 7–8. ↩
• Howard F. Chang, Immigration Policy, Liberal Principles, and the Republican Tradition , 85 Geo. L.J. 2105, 2109 (1997). ↩
• See Diamond, supra note 30, at 275–78. ↩
• Id. at 277. ↩
• Cortez, supra note 35, at 870 (footnotes omitted). ↩
• See Sarah Kliff & Ezra Klein, Individual Mandate 101: What It Is, and Why It Matters , Wash. Post , Mar. 27, 2012, http://www.washingtonpost.com/blogs/wonkblog/post/individual-mandate-101-what-it-is-why-it-matters/2011/08/25/gIQAhPzCeS_blog.html . ↩
• The U.S. Department of Health and Human Services recently issued a rule clarifying that individuals granted deferred action were not considered “lawfully present” under the law.  Robert Pear, Limits Placed on Immigrants in Health Care Law , N.Y. Times , Sept. 17, 2012, http://www.nytimes.com/2012/09/18/health/policy/limits-placed-on-immigrants-in-health-care-law.html . ↩
• Maggie Mertens, Health Care for All Leaves 23 Million Uninsured , NPR (Mar. 24, 2010, 10:37 AM), http://www.npr.org/blogs/health/2010/03/health_care_for_all_minus_23_m.html . ↩
• See supra notes 30, 38, and accompanying text. ↩
• Jennifer Ludden, Health Care Overhaul Ignores Illegal Immigrants , NPR (July 8, 2009, 12:00 AM), http://www.npr.org/templates/story/story.php?storyId=106376595 . ↩
• This Paper utilizes a narrow approach to legislative history, following the example of Lee Epstein & Gary King, The Rules of Inference , 69 U. Chi. L. Rev. 1, 75 (2002).  See Janet L. Dolgin & Katherine R. Dieterich, When Others Get Too Close: Immigrants, Class, and the Health Care Debate , 19 Cornell J.L. & Pub. Pol’y 283, 312–14 (2010) for a broader view of the ACA ’s legislative history with respect to the undocumented. ↩
• House Democrats Announce Health-Care Bill , Wash. Post , Oct. 29, 2009, ST2009102902154 " target="_blank" rel="noopener noreferrer">http://www.washingtonpost.com/wp-dyn/content/article/2009/10/29/AR2009102902240.html?sid= ST2009102902154 . ↩
• See, e.g. , id . (“It is with great pride and with great humility that we come before you to follow in the footsteps of those who gave our country Social Security and then Medicare and now universal, quality, affordable health care for all Americans.”) (statement of Rep. Nancy Pelosi); id. (“[W]e’re here at a historic time, when for over half a century a family elected by their citizens to come to this Congress have raised the banner of health care for all that they could afford.”) (statement of Rep. Steny Hoyer); id . (“47 million Americans who do not have health care will be grateful for this day . . . . This bill offer [sic] everyone, regardless of income, age, sex, health status, the peace of mind in knowing that they will have real access to quality, affordable health insurance when they need it.”) (statement of Rep. John Dingell). ↩
• Id. ; Who Are the Uninsured? , N.Y. Times , Aug. 23, 2009, http://prescriptions.blogs.nytimes.com/ 2009/08/23/who-are-the-uninsured . ↩
• E.g. , 155 Cong. Rec. H12 ,623, H12 ,848 (daily ed. Nov. 7, 2009) (“[T]his bill will do for America what we should have done 100 years ago: provide health care for all Americans as a matter of right, not as a matter of privilege.”) (statement of Rep. Braley); 155 Cong. Rec. H12 ,598, H12 ,619 (daily ed. Nov. 7, 2009) (“Every American deserves the promise of quality affordable health care, and this is our moment to fulfill that promise.”) (statement of Rep. Langevin); id. at H12 ,621 (“Let me be absolutely clear: every single American should have access to affordable and quality health-care coverage.”) (statement of Rep. Ackerman). ↩
• E.g. , 155 Cong. Rec. H12 ,623, H12 ,844 (daily ed. Nov. 7, 2009) (“We are creating a new health insurance marketplace and requiring everyone to have coverage, which I support.”) (statement of Rep. Frank); 155 Cong. Rec. H12 ,598, H12 ,611 (daily ed. Nov. 7, 2009) (“[I]t is clear that Congress needs to make reforms to expand health care coverage so that everyone in this great Nation has health insurance.”) (statement of Rep. Diaz-Balart); id. at H12 ,614 (“Six principles have guided my work and determined my vote on this legislation: health insurance reform must create stability, contain costs, guarantee choice, improve quality, cover everyone, and include a strong public option.  The Affordable Health Care for America Act delivers on each of these principles.”) (statement of Rep. Heinrich). ↩
• 155 Cong. Rec. H12 ,623, H12 ,851 (daily ed. Nov. 7, 2009) (“This bill cuts healthcare for our seniors by hundreds of billions of dollars while providing subsidized health care of illegal immigrants, which will draw more illegals into our country.”) (statement of Rep. Rohrabacher); id. at H12 ,870 (“As if that wasn’t enough, the bill opens the floodgates of taxpayer money for illegal immigrants to abuse the system and obtain free government health insurance—all on the backs of law-abiding Americans.”) (statement of Rep. Rogers). ↩
• Representative Holt stated, Another myth is that health reform would provide federal benefits for undocumented aliens. Undocumented immigrants currently may not receive any federal benefits except in specific emergency medical situations. There are no provisions in the House health reform bill that would change this policy. In fact, the legislation explicitly states that federal funds for insurance would not be available to any individual who is not lawfully present in the United States. ↩
• 155 Cong. Rec. H12 ,598, H12 ,620 (daily ed. Nov. 7, 2009) (emphasis added). ↩
• Id. at H12 ,615. ↩
• 155 Cong. Rec. H12 ,623, H12 ,899 (daily ed. Nov. 7, 2009). ↩
• Biden & Obama, supra note 2. ↩
• See Bryan J. Leitch, Comment, Where Law Meets Politics: Freedom of Contract, Federalism, and the Fight Over Health Care , 27 J.L. & Pol. 177, 178 (2011). ↩
• See Lance Gable, The Patient Protection and Affordable Care Act, Public Health, and the Elusive Target of Human Rights , 39 J.L. Med. & Ethics 340, 342 (2011). ↩
• See id. ; David U. Himmelstein & Steffie Woolhandler, Op-Ed, I Am Not a Health Reform , N.Y. Times , Dec. 15, 2007, http://www.nytimes.com/2007/12/15/opinion/15woolhandler.html (dis­cuss­ing President Nixon’s healthcare reform bill). ↩
• For example, see W. John Thomas, Play It Again, Hillary: A Dramaturgical Examination of a Repeat Health Care Plan Performance , 19 Stan. L. & Pol’y Rev. 283, 290 (2008), for a brief overview of the 1993 Health Care Reform Plan. ↩
• Adam Clymer, Hillary Clinton Courts Four Senators Backing Rival Health Care Proposal , N.Y. Times , Oct. 30, 1993, http://www.nytimes.com/1993/10/30/us/hillary-clinton-courts-four-senators-backing-rival-health-care-proposal.html . ↩
• See Health Care Reform May Leave Out Undocumented Aliens , 70 No. 35 Interpreter Releases 1195, 1195 (1993). ↩
• E.g. , 155 Cong. Reg. H12,598, H12 ,607 (daily ed. Nov. 7, 2009) (“Millions of illegal immigrants will receive taxpayer subsidies for enrollment in subsidized health care plans [under the initial House version of the ACA ].”) (statement of Rep. Posey); id. at H12 ,615 (“This massive government takeover of our health care still allows the 20 million people in this country that are illegally here to get one of those fake Social Security cards without benefit of even a photo ID and get some of that free government health care that everybody else has to pay for.”) (statement of Rep. Poe); 155 Cong. Rec. H12 ,623, H12 ,870 (daily ed. Nov. 7, 2009) (statement of Rep. Rogers); see also Dolgin & Dieterich, supra note 47, at 284. ↩
• 155 Cong. Rec. H12 ,623, H12 ,870 (daily ed. Nov. 7, 2009) (statement of Rep. Rogers). ↩
• See Julia Preston, Health Care Debate Focuses on Legal Immigrants , N.Y. Times , Nov. 3, 2009, http://www.nytimes.com/2009/11/04/health/policy/04immig.html . ↩
• Eduardo Porter, Illegal Immigrants Are Bolstering Social Security With Billions , N.Y. Times , Apr. 5, 2005, http://www.nytimes.com/2005/04/05/business/05immigration.html . ↩
• Nina Bernstein, Tax Returns Rise for Immigrants in U.S. Illegally , N.Y. Times , Apr. 16, 2007, http://www.nytimes.com/2007/04/16/nyregion/16immig.html . ↩
• Juliet Lapidos, Editorial, The 47 Percent , N.Y. Times (Sept. 18, 2012, 11:47 AM), http://takingnote.blogs.nytimes.com/2012/09/18/the-47-percent . ↩
• Brian Palmer, Exactly How Many Americans Are Dependent on the Government? , Slate (Sept. 18, 2012, 1:07 AM), http://www.slate.com/articles/news_and_politics/explainer/2012/09/romney_says_47_percent_of_americans_receive_direct_government_assistance_is_that_true_.html . ↩
• Cong. Budget Office, Immigration Policy in the United States 8 (2006) . ↩
• See Damien Cave, Better Lives for Mexicans Cut Allure of Going North , N.Y. Times , July 6, 2011, http://www.nytimes.com/interactive/2011/07/06/world/americas/immigration.html . ↩
• See , e.g. , Dayna Bowen Matthew, The Social Psychology of Limiting Healthcare Benefits for Undocumented Immigrants—Moving Beyond Race, Class, and Nativism , 10 Hous. J. Health L. & Pol’y 201, 204 (2010) (“[W]e know empirically that the sole or primary motivation to immigrate to the United States is not to participate in the healthcare system.”).  Matthew also posits a public health reason for extending health insurance coverage to all noncitizens: preventing the spread of treatable, communicable diseases.  See id. at 203. ↩
• See Michael Muskal, Illegal Immigration to U.S. Stays Down, Pew’s Latest Numbers Show , L.A. Times , Dec. 6, 2012, http://www.latimes.com/news/nation/nationnow/la-na-nn-pew-illegal-immigration-down-20121206,0,4267690.story (“The number of illegal immigrants in the U.S., which stood at about 8.4 million in 2000, peaked at about 12 million in 2007 and has been tapering since . . . .”). ↩
• Further, the Mexican economy has improved in the last few years, dissuading many Mexicans from leaving home to enter the United States.  See Cave, supra note 75.  Some, however, also credit increased enforcement efforts with the decrease in the U.S. undocumented population.  Matthew, supra note 76, at 202. ↩
• See Christopher M. Hughes, Op-Ed, Health Care for All: Expanding Medicaid Would Save Lives, Suffering and Money , Pittsburgh Post-Gazette (Oct. 4, 2012, 12:17 AM), http://www.post-gazette.com/stories/opinion/perspectives/health-care-for-all-expanding-medicaid-would-save-lives-suffering-and-money-656060 . ↩
• Ludden, supra note 46. ↩
• Patrick J. Glen, Health Care and the Illegal Immigrant 58 (Georgetown Pub. Law & Legal Theory Research Paper No. 12-024, 2012). ↩
• E.g. , James C. Capretta, Obamacare: Impact on Future Generations , Heritage Found. (June 1, 2010), http://www.heritage.org/research/reports/2010/06/obamacare-impact-on-future-generations . ↩
• See Ezekiel J. Emanuel, Op-Ed, Saving by the Bundle , N.Y. Times (Nov. 16, 2011, 7:55 PM), http://opinionator.blogs.nytimes.com/2011/11/16/saving-by-the-bundle ; see also Ann Weilbaecher, Immigrant Health Care: Social and Economic Costs of Denying Access , 17 Annals Health L. 337, 337–38 (2008); Ludden, supra note 46. ↩
• See, e.g. , 155 Cong. Rec. H12 ,598, H12 ,616 (daily ed. Nov. 7, 2009) (“[T]oo many people in America are uninsured, 47 million.  Well, subtract from that 47 million illegal aliens which will be funded under this bill, immigrants, those that qualify for Medicaid and other government programs, employer programs that make over ,000 a year, now you’re down to really only 12.1 million Americans who are without affordable options.  That is less than 4 percent of America.  And for that you would throw out the liberty of America, throw out the baby with the bathwater of the best health insurance industry in the world, the best health care delivery system in the world, destroyed by a desire to create a dependency society to steal our freedom.”) (statement of Rep. King). ↩
• For support of this theory, see Dolgin & Dieterich, supra note 47, at 312–13. ↩
• See supra note 52 and accompanying text. ↩
• See Biden & Obama, supra note 2. ↩
• See supra notes 63–65 and accompanying text. ↩
• See supra note 53 and accompanying text. ↩
• See John F. Manning, The New Purposivism , 2011 Sup. Ct. Rev. 113, 172 (cautioning against over-analyzing the breadth of a term used in the legislative history such as “substantially all”). ↩
• See supra note 84. ↩
• Dolgin & Dieterich, supra note 47, at 311–25. ↩
• Black-White Conflict Isn’t Society’s Largest , Pew Res. Ctr. (Sept. 24, 2009), http://www.pewsocialtrends.org/2009/09/24/black-white-conflict-isnt-societys-largest . ↩
• See Matthew, supra note 76, at 222 (discussing the “Us-Them dichotomy” espoused by many “in-group” Americans). ↩
• See id. at 201 (quoting Otis L Graham, The Unfinished Reform: Regulating Immigration in the National Interest , in Debating American Immigration, 1882–Present 89, 91 (2001)). ↩
• Dolgin & Dieterich, supra note 47, at 285 (“[I]mmigrants—especially undocumented, Hispanic immigrants—have become scapegoats on which social discontent and economic anxiety are displaced.”).  See generally Mark Hugo Lopez et al., Pew Hispanic Ctr., Illegal Immigration Backlash Worries, Divides Latinos (2010) (explaining how animosity towards the undocumented has led to Latinos fearing prejudice and discrimination based on their ethnic characteristics, regardless of their immigration status). ↩
• See, e.g. , Olga Popov, Note, Towards A Theory of Underclass Review , 43 Stan. L. Rev. 1095, 1099 (1991). ↩
• Matthew, supra note 76, at 202. ↩
• See Dolgin & Dietrich, supra note 47, at 312–14, for a discussion suggesting that the ACA ’s proponents neglected to include the undocumented in the bill because it would be “politically explosive.” ↩
• See supra note 58 and accompanying text identifying the dearth of legislative history regarding reasons for giving reduced protections for these two groups under the ACA . ↩
• Most conceptions of comprehensive immigration reform include a path to citizenship for at least some portion of the undocumented community.  See Understanding Immigration Reform , N.Y. Times , Dec. 9, 2012, http://www.nytimes.com/roomfordebate/2012/12/09/understanding-immigration-reform ; see also Preston, supra note 69 (“‘We are not trying to expand health care coverage to illegal immigrants through this legislation,’ said Senator Jeff Bingaman, Democrat of New Mexico.  ‘That will have to be dealt with through comprehensive immigration reform.’”). ↩
• See supra note 36. ↩
• See Editorial, Inching Toward Immigration Reform , Wash. Post , Nov. 30, 2012, http://www.washingtonpost.com/opinions/inching-toward-immigration-reform/2012/11/30/3a016b70-38e0-11e2-8a97-363b0f9a0ab3_story.html . ↩
• See, e.g. , supra note 43 and accompanying text. ↩
• See Matthew, supra note 76, at 225. ↩

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Dylan Scott answers 9 key questions about universal health care around the world

Vox policy reporter Dylan Scott traveled to Taiwan, Australia, and the Netherlands to see their health systems.

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Vox policy reporter Dylan Scott traveled the world last fall to explore what the US can learn from other countries’ health systems , visiting Taiwan, Australia, and the Netherlands. His trips were the foundation for Everybody Covered , a Vox series on health care that also reported on health systems in the United Kingdom and Maryland .

Dylan did a Reddit Ask Me Anything session on Wednesday, January 29, discussing everything from how countries pay for universal health care to what it will take to achieve further health care reform in America. Here’s a roundup of some of the most interesting questions and answers, lightly edited for clarity.

1) How do countries pay for public health insurance?

Icantnotthink: Where does the payment for public health care come from in other countries?

Dylan: Most of these countries use some mix of 1) payroll taxes for individuals, 2) employer contributions, and 3) general government revenue and progressive/sin taxes. To be honest, there isn’t one model to follow. Each country had its own health funding plan that has since been reformed to meet the needs of their current system, just as the US would. But other countries are looking for health care dollars in many of the same places Medicare-for-all supporters think we should here.

2) When it comes to covering everyone, is a country’s population density important?

Verybalnduser: How important would you say a country’s population density is to keeping total cost down?

Dylan Scott: It’s a huge asset. Taiwan has been able to keep its overall spending low — people on the left would say their single-payer program is actually underfunded — and cost sharing low for patients in large part because its urbanized nature makes it easier for a smaller workforce to meet the needs of its patient population. The Netherlands has been very innovative in delivery reforms, meant to keep costs in check, something that’s clearly been aided by its density. Australia , on the other hand, even with a universal public insurance plan, has still struggled with access in its more rural areas.

3) Is there a lot of paperwork in a single-payer system?

ZenBacle: How much paperwork do patients in single-payer systems have to fill out? And how much time do those patients have to spend fighting with health care providers to get them to honor their coverage?

Dylan Scott: One of the benefits of single-payer is there’s a lot less administration. We visited a hospital in Taipei, Taiwan, and while all the clinic lobbies were full, the cashier’s desk was basically empty. One survey finding that stuck out to me showed the doctors in the Netherlands (with private insurance) are more annoyed about paperwork than their peers in more socialized systems. So while I wouldn’t want to try to quantify it off the top of my head, there seems to be less of a paperwork headache.

Everybody Covered

What the US can learn from other countries’ health systems

• Taiwan’s single-payer success story — and its lessons for America
• Two sisters. Two different journeys through Australia’s health care system.
• The Netherlands has universal health insurance — and it’s all private
• The answer to America’s health care cost problem might be in Maryland
• In the UK’s health system, rationing isn’t a dirty word

4) Between Taiwan, Australia, and the Netherlands, which policy would translate most easily to the US?

Doctor_YOOOOU: Which of these universal health care systems is “closest” in terms of the amount of reform required to the United States?

Dylan: This is a tricky one — no country looks much like the US status quo. The Netherlands does have a lot of the same features as Obamacare (ban on preexisting conditions, individual mandate, government assistance to cover the costs), but it’s available to everybody and it’s stricter. The mandate penalty is harsher, the government rules on cost sharing are more stringent, and the government actually helps set prices and an overall budget for health care. So it’s much more involved than the US government is in administering that private health insurance. And almost all of the insurers are nonprofits.

So we’re talking about huge changes to move the US system to something that looks more like the Dutch — and that’s one I’d name as closest (along with Japan) to what we have right now.

5) Do solutions exist within the US that can be applied to the rest of the country?

Blakestonefeather: You traveled the world to explore what the US can learn, but did you also travel the US to learn if the US can learn? [In other words,] what are the barriers we in America face to learning/being able to learn?

Dylan Scott: We actually did one story in the US, on Maryland’s unique system for paying hospitals . (Every insurer — private, Medicare and Medicaid — pays the same rates for the same services.)

But there is a huge challenge in translating policies from abroad to the US. Taiwan and Australia have about the same population as Texas, but Taiwan’s is contained to a tiny island off the coast of China and Australia is a continent. The Netherlands is one of the most densely populated countries in the world; the United States is one of the least.

Then you’ve got political differences; Princeton economist Uwe Reinhardt famously didn’t believe single-payer could work in the US, not because it’s not a good idea but because the government was too beholden to corporate interests. The recent failure of surprise billing legislation in Congress in the face of industry opposition is certainly a warning sign to any aspiring reformers.

So the dissatisfying answer to “so what can the US learn from these other countries’ successes?” is: It’s complicated. But my hope for this series is it would speak to the kinds of values and strategies, if less the specific policies, that are necessary to achieve universal health care.

6) What does the American health care system get right?

taksark: What’s something good about the American health care system that could be kept and improved on in a better version?

Dylan Scott: The geographic immensity of the US has forced a lot of experimentation with telemedicine, and that is both a necessity and an area where other countries have tried to draw from what the US has done. I heard a lot from doctors about coming to the US to learn the latest on best practices for delivering care.

I think the US is still seen as a leader in innovative medicine — the question is why can’t we give more people access to it?

7) Besides America, what other countries have private health insurance?

To_Much_Too_Soon: How many other countries besides America have private health insurance?

Dylan: The US relies much more on private health insurance than any other country I’m aware of. About half of US citizens depend on private insurance as their primary coverage, and about 8 percent of our GDP is private health spending; most other developed economies don’t top 4 percent of GDP for private spending.

There are countries like the Netherlands with universal private insurance. But their private insurance is a lot different than ours: Almost all of the insurers are nonprofits, the government sets rules about premiums and cost sharing, there is a global budget for health care costs, etc.

Some countries with single-payer programs, like Australia, allow private insurance as a supplement — so you can get more choice in doctor or can skip the line for surgery. But no developed economy I know of is so dependent on private insurance as the US and with comparatively few regulations about its benefits.

8) What surprised you the most throughout your reporting?

JoseyGunner: What shocked you the most during your travels?

Dylan Scott: I was surprised how often people I talked to were shocked by the worst parts of US health care. The uninsured rates, the deductibles we have to pay, the very idea of a surprise medical bill — all of it was unfathomable to many of the people I met.

9) What are the biggest hurdles to any future health reforms in the US?

Flogopickles: What do you see as America’s biggest hurdle to achieving any sort of movement in affordable care for our citizens?

Dylan Scott: The status quo is powerful for two reasons: One, it’s good enough for enough people that big change feels like a risky proposition to a lot of the population and, two, health industry interests are so influential in Washington, DC. Overcoming those two things — people’s inherent aversion to risk in health care and the power of industry to constrain policymaking, especially price constraints for medical care — are the biggest hurdles to any future health reforms.

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Guest Essay

We’re Already Paying for Universal Health Care. Why Don’t We Have It?

By Liran Einav and Amy Finkelstein

Dr. Einav is a professor of economics at Stanford. Dr. Finkelstein is a professor of economics at the Massachusetts Institute of Technology.

There is no shortage of proposals for health insurance reform, and they all miss the point. They invariably focus on the nearly 30 million Americans who lack insurance at any given time. But the coverage for the many more Americans who are fortunate enough to have insurance is deeply flawed.

Health insurance is supposed to provide financial protection against the medical costs of poor health. Yet many insured people still face the risk of enormous medical bills for their “covered” care. A team of researchers estimated that as of mid-2020, collections agencies held $140 billion in unpaid medical bills, reflecting care delivered before the Covid-19 pandemic. To put that number in perspective, that’s more than the amount held by collection agencies for all other consumer debt from nonmedical sources combined. As economists who study health insurance, what we found really shocking was our calculation that three-fifths of that debt was incurred by households with health insurance.

What’s more, in any given month, about 11 percent of Americans younger than 65 are uninsured, and more than twice that number will be uninsured for at least some time over a two-year period. Many more face the constant danger of losing their coverage. Perversely, health insurance — the very purpose of which is to provide a measure of stability in an uncertain world — is itself highly uncertain. And while the Affordable Care Act substantially reduced the share of Americans who are uninsured at a given time, we found that it did little to reduce the risk of insurance loss among the currently insured.

It’s tempting to think that incremental reforms could address these problems. For example, extend coverage to those who lack formal insurance; make sure all insurance plans meet some minimum standards; change the laws so that people don’t face the risk of losing their health insurance coverage when they get sick, when they get well (yes, that can happen) or when they change jobs, give birth or move.

But those incremental reforms won’t work. Over a half-century of such well-intentioned, piecemeal policies has made clear that continuing this approach represents the triumph of hope over experience, to borrow a description of second marriages commonly attributed to Oscar Wilde.

The risk of losing coverage is an inevitable consequence of a lack of universal coverage. Whenever there are varied pathways to eligibility, there will be many people who fail to find their path.

About six in 10 uninsured Americans are eligible for free or heavily discounted insurance coverage. Yet they remain uninsured. Lack of information about which of the array of programs they are eligible for, along with the difficulties of applying and demonstrating eligibility, mean that the coverage programs are destined to deliver less than they could.

The only solution is universal coverage that is automatic, free and basic.

Automatic because when we require people to sign up, not all of them do. The experience with the health insurance mandate under the Affordable Care Act makes that clear.

Coverage needs to be free at the point of care — no co-pays or deductibles — because leaving patients on the hook for large medical costs is contrary to the purpose of insurance. A natural rejoinder is to go for small co-pays — a $5 co-pay for prescription drugs or $20 for a doctor visit — so that patients make more judicious choices about when to see a health care professional. Economists have preached the virtues of this approach for generations.

But it turns out there’s an important practical wrinkle with asking patients to pay even a very small amount for some of their universally covered care: There will always be people who can’t manage even modest co-pays . Britain, for example, introduced co-pays for prescription drugs but then also created programs to cover those co-pays for most patients — elderly and young people, students, veterans and those who are pregnant, low income or suffering from certain diseases. All told, about 90 percent of prescriptions are exempted from the co-pays and dispensed free. The net result has been to add hassles for patients and administrative costs for the government, with little impact on the patients’ share of total health care costs or total national health care spending.

Finally, coverage must be basic because we are bound by the social contract to provide essential medical care, not a high-end experience. Those who can afford and want to can purchase supplemental coverage in a well-functioning market.

Here, an analogy to airline travel may be useful. The main function of an airplane is to move its passengers from point A to point B. Almost everyone would prefer more legroom, unlimited checked bags, free food and high-speed internet. Those who have the money and want to do so can upgrade to business class. But if our social contract were to make sure everyone could fly from A to B, a budget airline would suffice. Anyone who’s traveled on the low-cost airlines that have transformed airline markets in Europe knows it is not a wonderful experience. But they do get you to your destination.

Keeping universal coverage basic will keep the cost to the taxpayer down as well. It’s true that as a share of its economy, the United States spends about twice as much on health care as other high-income countries. But in most other wealthy countries, this care is primarily financed by taxes, whereas only about half of U.S. health care spending is financed by taxes. For those of you following the math, half of twice as much is … well, the same amount of taxpayer-financed spending on health care as a share of the economy. In other words, U.S. taxes are already paying for the cost of universal basic coverage. Americans are just not getting it. They could be.

We arrived at this proposal by using the approach that comes naturally to us from our economics training. We first defined the objective, namely the problem we are trying but failing to solve with our current U.S. health policy. Then we considered how best to achieve that goal.

Nonetheless, once we did this, we were struck — and humbled — by the realization that at a high level, the key elements of our proposal are ones that every other high-income country (and all but a few Canadian provinces) has embraced: guaranteed basic coverage and the option for people to purchase upgrades.

The lack of universal U.S. health insurance may be exceptional. The fix, it turns out, is not.

Liran Einav is a professor of economics at Stanford. Amy Finkelstein is a professor of economics at M.I.T. They are the authors of the forthcoming book “ We’ve Got You Covered : Rebooting American Health Care,” from which this essay was adapted.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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15.10 Persuasive Essay

Learning objective.

• Read an example of the persuasive rhetorical mode.

Universal Health Care Coverage for the United States

The United States is the only modernized Western nation that does not offer publicly funded health care to all its citizens; the costs of health care for the uninsured in the United States are prohibitive, and the practices of insurance companies are often more interested in profit margins than providing health care. These conditions are incompatible with US ideals and standards, and it is time for the US government to provide universal health care coverage for all its citizens. Like education, health care should be considered a fundamental right of all US citizens, not simply a privilege for the upper and middle classes.

One of the most common arguments against providing universal health care coverage (UHC) is that it will cost too much money. In other words, UHC would raise taxes too much. While providing health care for all US citizens would cost a lot of money for every tax-paying citizen, citizens need to examine exactly how much money it would cost, and more important, how much money is “too much” when it comes to opening up health care for all. Those who have health insurance already pay too much money, and those without coverage are charged unfathomable amounts. The cost of publicly funded health care versus the cost of current insurance premiums is unclear. In fact, some Americans, especially those in lower income brackets, could stand to pay less than their current premiums.

However, even if UHC would cost Americans a bit more money each year, we ought to reflect on what type of country we would like to live in, and what types of morals we represent if we are more willing to deny health care to others on the basis of saving a couple hundred dollars per year. In a system that privileges capitalism and rugged individualism, little room remains for compassion and love. It is time that Americans realize the amorality of US hospitals forced to turn away the sick and poor. UHC is a health care system that aligns more closely with the core values that so many Americans espouse and respect, and it is time to realize its potential.

Another common argument against UHC in the United States is that other comparable national health care systems, like that of England, France, or Canada, are bankrupt or rife with problems. UHC opponents claim that sick patients in these countries often wait in long lines or long wait lists for basic health care. Opponents also commonly accuse these systems of being unable to pay for themselves, racking up huge deficits year after year. A fair amount of truth lies in these claims, but Americans must remember to put those problems in context with the problems of the current US system as well. It is true that people often wait to see a doctor in countries with UHC, but we in the United States wait as well, and we often schedule appointments weeks in advance, only to have onerous waits in the doctor’s “waiting rooms.”

Critical and urgent care abroad is always treated urgently, much the same as it is treated in the United States. The main difference there, however, is cost. Even health insurance policy holders are not safe from the costs of health care in the United States. Each day an American acquires a form of cancer, and the only effective treatment might be considered “experimental” by an insurance company and thus is not covered. Without medical coverage, the patient must pay for the treatment out of pocket. But these costs may be so prohibitive that the patient will either opt for a less effective, but covered, treatment; opt for no treatment at all; or attempt to pay the costs of treatment and experience unimaginable financial consequences. Medical bills in these cases can easily rise into the hundreds of thousands of dollars, which is enough to force even wealthy families out of their homes and into perpetual debt. Even though each American could someday face this unfortunate situation, many still choose to take the financial risk. Instead of gambling with health and financial welfare, US citizens should press their representatives to set up UHC, where their coverage will be guaranteed and affordable.

Despite the opponents’ claims against UHC, a universal system will save lives and encourage the health of all Americans. Why has public education been so easily accepted, but not public health care? It is time for Americans to start thinking socially about health in the same ways they think about education and police services: as rights of US citizens.

Online Persuasive Essay Alternatives

Martin Luther King Jr. writes persuasively about civil disobedience in Letter from Birmingham Jail :

• http://www.stanford.edu/group/King/frequentdocs/birmingham.pdf
• http://web.cn.edu/kwheeler/documents/Letter_Birmingham_Jail.pdf
• http://www.oak-tree.us/stuff/King-Birmingham.pdf

Michael Levin argues The Case for Torture :

• http://people.brandeis.edu/~teuber/torture.html

Alan Dershowitz argues The Case for Torture Warrants :

• http://blogs.reuters.com/great-debate/2011/09/07/the-case-for-torture-warrants/

Alisa Solomon argues The Case against Torture :

• http://www.villagevoice.com/2001-11-27/news/the-case-against-torture/1

Writing for Success Copyright © 2015 by University of Minnesota is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

Point Turning Point: the Case for Universal Health Care

An argument that the COVID-19 pandemic might be the turning point for universal health care.

Why the U.S. Needs Universal Health Care

As we all grapple with our new reality, it's difficult to think of anything beyond the basics. How do we keep our families safe? Are we washing our hands enough ? Do we really have to sanitize the doorknobs and surfaces every day? How do we get our cats to stop videobombing our Zoom meetings? Do we have enough toilet paper?

Win McNamee | Getty Images

The more we read the headlines, the more we feel the need to do something, or at least say something. Change is happening – ready or not. Maybe talking about some of these important issues can lead to action that will help us steer out of this skid.

Historically, Americans have found ways to meet their circumstances with intention, moving in mass to make heretofore unimaginable change that has sustained and improved our lives to this day. The Great Depression lead to the creation of the New Deal and Social Security. The Triangle Shirtwaist Factory fire brought about change in labor conditions. The Cuyahoga River fire lead to the founding of the Environmental Protection Agency.

Could the COVID-19 pandemic be the turning point for universal health care? We can't think of a more propitious time. In the first two weeks of April, 5.2 million Americans filed for unemployment. Economists believe that 30% unemployment is possible by fall. For most Americans, our health care is tied to our employment, and because of this, millions of Americans are losing their health care just when they may need it the most. Economists predict that health insurance premiums will likely increase by 40% in the next year due to less payers and more who are in need of care and the eventual collapse of private health care insurance .

Our current circumstances have illustrated the need for universal health care in a way that is obvious and undeniable. Below we have listed the most frequent arguments in opposition followed by an evidence-based rebuttal.

1. Point: "Governments are wasteful and shouldn't be in charge of health care."

Counterpoint: In 2017, the U.S. spent twice as much on health care (17.1% of GDP) as comparable Organization for Economic Co-Operation and Development countries (OECD) (8.8% of GDP), all of whom have universal health care. The country with the second highest expenditure after the U.S. is Switzerland at 12.3%, nearly 5% less. Of all these countries, the U.S. has the highest portion of private insurance. In terms of dollars spent, the average per capita health care spending of OECD countries is $3,558, while in the U.S. it's $10,207 – nearly three times as costly.

Bottom line: Among industrialized countries with comparable levels of economic development, government-provided health care is much more efficient and more economical than the U.S. system of private insurance.

2. Point: "U.S. health care is superior to the care offered by countries with universal health care."

Counterpoint: According to the Commonwealth Health Fund , in the U.S., infant mortality is higher and the life span is shorter than among all comparable economies that provide universal health care. Maternal mortality in the U.S. is 30 per 100,000 births and 6.4 per 100,000 births on average in comparable countries, which is nearly five times worse.

In addition, the U.S. has the highest chronic disease burden (e.g., diabetes, hypertension) and an obesity rate that is two times higher than the OECD average. In part due to these neglected conditions, in comparison to comparable countries, the U.S. (as of 2016) had among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.

The Peterson-Kaiser Health System Tracker , which is a collaborative effort to monitor the quality and cost of U.S. health care, shows that among comparable countries with universal health care, mortality rate is lower across the board on everything from heart attacks to child birth. The U.S. also has higher rates of medical, medication and lab errors relative to similar countries with universal health care.

Bottom line: With our largely privately funded health care system, we are paying more than twice as much as other countries for worse outcomes.

3. Point: "Universal health care would be more expensive."

Counterpoint: The main reason U.S. health care costs are so high is because we don't have universal health care. Unlike other first world countries, the health care system in the U.S. is, to a great extent, run through a group of businesses. Pharmaceutical companies are businesses. Insurance companies are businesses. Hospital conglomerates are businesses. Even doctors' offices are businesses.

Businesses are driven to streamline and to cut costs because their primary goal is to make a profit. If they don't do this, they can't stay in business. It could mean that in the process of "streamlining," they would be tempted to cut costs by cutting care. Under the current system, a share of our health care dollars goes to dividends rather than to pay for care, hospitals are considered a "financial asset" rather than a public service entity and a large portion of their budgets are dedicated to marketing rather than patient care.

Given all these business expenses, it shouldn't be surprising that the business-oriented privately funded health care system we have is more expensive and less effective than a government provided universal system. In addition, for the health care system as a whole, universal health care would mean a massive paperwork reduction. A universal system would eliminate the need to deal with all the different insurance forms and the negotiations over provider limitations. As a result, this would eliminate a large expense for both doctors and hospitals.

The economist Robert Kuttner critiques the system this way: "For-profit chains … claim to increase efficiencies by centralizing administration, cutting waste, buying supplies in bulk at discounted rates, negotiating discounted fees with medical professionals, shifting to less wasteful forms of care and consolidating duplicative facilities." As he points out, "using that logic, the most efficient 'chain' of all is a universal national system."

Evidence to support these points can be found in a recent Yale University study that showed that single-payer Medicare For All would result in a 13% savings in national health-care expenditures. This would save the country $450 billion annually.

Bottom line: Universal health care would be less expensive overall, and an added benefit would be that health care decisions would be put in the hands of doctors rather than insurance companies, which have allegiances to shareholders instead of patient care.

4. Point: "I have to take care of my own family. I can't afford to worry about other people."

Counterpoint: It is in all of our best interests to take care of everyone. Aside from the fact that it is the compassionate and moral thing to do, viruses do not discriminate. When people don't have insurance, they won't go to the doctor unless they're gravely ill. Then, they're more likely to spread illness to you and your family members while they delay getting the care they need.

In addition, when people wait for care or don't get the prophylactic care then need, they end up in the emergency room worse off with more costly complications and requiring more resources than if they had been treated earlier. Taxpayers currently cover this cost. This affects everyone, insured or not. Why not prevent the delay upfront and make it easy for the patient to get treatment early and, as an added bonus, cost everyone less money?

In addition, the health of the economy impacts everyone. Healthy workers are essential to healthy businesses and thus a healthy economy. According to the Harvard School of Public Health , people who are able to maintain their health are more likely to spend their money on goods and services that drive the economy.

Bottom line: The health of others is relevant to the health of our families either through containment of infectious diseases such as COVID-19 or through the stability of the economy. Capitalism works best with a healthy workforce.

5. Point: "Entrepreneurship and innovation is what makes the U.S. a world leader."

Counterpoint: Imagine how many people in the U.S. could start their own businesses or bring their ideas to market if they didn't have to worry about maintaining health care for their families. So many people stay tethered to jobs they hate just so their family has health care. With workers not needing to stay in jobs they don't like in order to secure health insurance, universal healthcare would enable people to acquire jobs where they would be happier and more productive. Workers who wanted to start their own business could more easily do so, allowing them to enter the most creative and innovative part of our economy – small businesses.

In his book, "Everything for Sale," economist Robert Kuttner asserts that it's important to understand that businesses outside of the U.S. don't have to provide health care for their employees, which makes them more competitive. From a business point of view, American companies, released from the burden of paying employee insurance, would be more competitive internationally. They would also be more profitable as they wouldn't have to do all the paperwork and the negotiating involved with being the intermediary between employees and insurance companies.

Bottom line: Unburdening businesses from the responsibility of providing health insurance for their employees would increase competitiveness as well as encourage entrepreneurship and innovation, and allow small businesses room to thrive.

6. Point: "The wait times are too long in countries with universal health care."

Counterpoint: The wait times on average are no longer in countries with universal healthcare than they are in the U.S., according to the Peterson-Kaiser Health System Tracker . In some cases, the wait times are longer in the U.S., with insurance companies using valuable time with their requirements to obtain referrals and approvals for sometimes urgently needed treatments. On average, residents of Germany, France, UK, Australia, and the Netherlands reported shorter wait times relative to the U.S.

Bottom line: Wait times are longer in the U.S. when compared with many countries with a universal health care system.

7. Point: "My insurance is working just fine, so why change anything?"

Counterpoint: A comprehensive study conducted in 2018 found that 62% of bankruptcies are due to medical bills and, of those, 75% were insured at the time. Most people who have insurance are insufficiently covered and are one accident, cancer diagnosis or heart attack away from going bankrupt and losing everything. The U.S. is the only industrialized country in the world whose citizens go bankrupt due to medical bills. And, if you survive a serious illness and don't go bankrupt, you may end up buried in bills and paperwork from your insurance company and medical providers. All of this takes time and energy that would be better spent healing or caring for our loved ones. Besides, we don't need to abolish private health insurance. Some countries like Germany have a two-tiered system that provides basic non-profit care for all but also allows citizens to purchase premium plans through private companies.

Bottom line: Private insurance does not protect against medical bankruptcy, but universal health care does. The residents of countries with universal health care do not go bankrupt due to medical bills.

8. Point: "I don't worry about losing my insurance because if I lose my job, I can just get another one."

Counterpoint: We can't predict what will happen with the economy and whether another job will be available to us. This pandemic has proven that it can all go bad overnight. In addition, if you lose your job, there is less and less guarantee that you will find a new job that provides insurance . Providing insurance, because it is so expensive, has become an increasingly difficult thing for companies to do. Even if you're able to find a company that provides health care when you change jobs, you would be relying on your employer to choose your health plan. This means that the employee assumes that the company has his or her best interests in mind when making that choice, rather than prioritizing the bottom line for the benefit of the business. Even if they're not trying to maximize their profit, many companies have been forced to reduce the quality of the insurance they provide to their workers, simply out of the need to be more competitive or maintain solvency.

Bottom line: There are too many factors beyond our control (e.g., pandemic, disability, economic recession) to ensure anyone's employment and, thus, health care. Universal health care would guarantee basic care. Nobody would have to go without care due to a job loss, there would be greater control over costs and businesses would not have to fold due to the exorbitant and rising cost of providing health insurance to their employees.

9. Point: "Pharmaceutical companies need to charge so much because of research and development."

Counterpoint: It's usually not the pharmaceutical companies developing new drugs. They develop similar drugs that are variations on existing drugs, altered slightly so that they can claim a new patent. Or they buy out smaller companies that developed new drugs, thus minimizing their own R&D costs. Most commonly, they manufacture drugs developed under funding from the National Institutes of Health, and thus, the tax payers are the greatest funder of drug development via NIH grants provided to university labs.

Oddly, this investment in R&D does not appear to extend any discount to the tax payers themselves. In "The Deadly Costs of Insulin, " the author writes that insulin was developed in a university lab in 1936. In 1996, the cost of a vial of insulin was $21. Today, the cost of a vial of insulin could be as much as $500, causing some without insurance to risk their lives by rationing or going without. The cost of manufacturing the drug has not gone up during that time. So, what accounts for the huge increase in price? In " The Truth About Drug Companies ," the author demonstrates that drug companies use the bulk of their profits for advertising, not R&D or manufacturing. A universal health care system would not only not need to advertise, but would also be more effective at negotiating fair drug prices. Essentially, the government as a very large entity could negotiate price much more effectively as one large system with the government as the largest purchaser.

Bottom line: Taxpayers contribute most of the money that goes into drug development. Shouldn't they also reap some of the benefits of their contribution to R&D? Americans should not have to decide between their heart medication and putting food on the table when their tax dollars have paid for the development of many of these medications.

10. Point: "I don't want my taxes to go up."

Counterpoint: Health care costs and deductibles will go down to zero and more than compensate for any increase in taxes, and overall health care needs will be paid for, not just catastrophic health events. According to the New York Times , “…when an American family earns around $43,000, half of the average compensation when including cash wages plus employer payroll tax and premium contributions, 37% of that ends up going to taxes and health care premiums. In high-tax Finland, the same type of family pays 23% of their compensation in labor taxes, which includes taxes they pay to support universal health care. In France, it’s 2%. In the United Kingdom and Canada, it is less than 0% after government benefits.”

Bottom line: With a universal health care system, health care costs and deductibles will be eliminated and compensate for any increase in taxes.

11. Point: "I don't want to have to pay for health care for people making bad choices or to cover their pre-existing conditions."

Counterpoint: Many of the health problems on the pre-existing conditions list are common, genetically influenced and often unavoidable. One estimate indicates that up to 50% – half! – of all (non-elderly) adults have a pre-existing condition. Conditions on the list include anxiety, arthritis, asthma, cancer, depression, heart defect, menstrual irregularities, stroke and even pregnancy. With universal health care, no one would be denied coverage.

It's easy to assume that your health is under your control, until you get into an accident, are diagnosed with cancer or have a child born prematurely. All of a sudden, your own or your child's life may rely on health care that costs thousands or even millions of dollars. The health insurance that you once thought of as "good enough" may no longer suffice, bankruptcy may become unavoidable and you (or your child) will forever have a pre-existing condition. Some people may seem careless with their health, but who's to judge what an avoidable health problem is, vs. one that was beyond their control?

For the sake of argument, let's say that there are some folks in the mix who are engaging in poor health-related behaviors. Do we really want to withhold quality care from everyone because some don't take care of their health in the way we think they should? Extending that supposition, we would withhold public education just because not everyone takes it seriously.

Bottom line: In 2014, protections for pre-existing conditions were put in place under the Affordable Care Act. This protection is under continuous threat as insurance company profits are placed above patient care. Universal health care would ensure that everyone was eligible for care regardless of any conditions they may have.

And, if universal health care is so awful, why has every other first-world nation implemented it? These countries include: Australia, Austria, Bahrain, Belgium, Brunei, Canada, Cyprus, Denmark, Finland, France, Germany, Greece, Hong Kong, Iceland, Ireland, Israel, Italy, Japan, Kuwait, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Singapore, Slovenia, South Korea, Spain, Sweden, Switzerland, United Arab Emirates and the U.K.

Changing collective minds can seem impossible. But there is precedent. Once unimaginable large-scale change has happened in our lifetime (e.g. legalization of gay marriage, election of the first black president of the U.S. and the #MeToo movement), and support for universal health care has never been higher (71% in favor, according to a 2019 Hill-HarrisX survey ).

Point: As Chuck Pagano said, "If you don't have your health, you don't have anything."

Counterpoint: If good health is everything, why don't we vote as if our lives depended on it? This pandemic has taught us that it does.

Bottom line: Launching universal health care in the U.S. could be a silver lining in the dark cloud of this pandemic. Rather than pay lip service to what really matters, let's actually do something by putting our votes in service of what we really care about: the long-term physical and economic health of our families, our communities and our country.

Photos: Hospital Heroes

Tags: health insurance , health care , Coronavirus , pandemic , New Normal

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• v.105(Suppl 5); Nov 2015

Universal Health Coverage: A Political Struggle and Governance Challenge

S. L. Greer led the development and writing of the article, including preparation of the initial outline. C. A. Méndez contributed to the conceptualization of the article and reviewed the drafts.

Universal health coverage has become a rallying cry in health policy, but it is often presented as a consensual, technical project. It is not.

A review of the broader international literature on the origins of universal coverage shows that it is intrinsically political and cannot be achieved without recognition of its dependence on, and consequences for, both governance and politics.

On one hand, a variety of comparative research has shown that health coverage is associated with democratic political accountability. Democratization, and in particular left-wing parties, gives governments particular cause to expand health coverage. On the other hand, governance, the ways states make and implement decisions, shapes any decision to strive for universal health coverage and the shape of its implementation.

Universal health coverage (UHC) has become a focal point in global health conversations. In the spirit of previous unifying concepts such as Health for All, basic health needs, and the Alma-Ata declaration, it presents a vision in which all citizens will enjoy (1) a strong and efficient health system that spans preventive and curative medicine, (2) affordable access to that health system, (3) access to relevant medicines, and (4) sufficient human resources for the health system. The 2010 World Health Report presented UHC as an objective and a strategy for its member states to reform, or design, their health systems. 1 UHC has been the focus of much research and policy prescription since then. Various authors have shown its implications for the health workforce and its governance, 2,3 health financing, 4 and management. 5

But is UHC likely to be attained? We draw on political science and public health literature to argue that politics and governance have been undervalued as key drivers for universal health coverage.

UNIVERSAL HEALTH COVERAGE IS POLITICAL

It is a political victory that UHC is discussed at all, and still more so that it has any veneer of consensus. UHC is a highly political concept. In the world of global health governance, it is part of an ongoing debate about the relative importance of “vertical” priorities such as disease eradication and broader “horizontal” system-strengthening proposals. 6,7 Given the momentum behind disease-specific interventions and the appeal of solving particular problems (e.g., antiretrovirals or polio eradication), it is always difficult to argue for more amorphous health system goals that are part of UHC or predecessor agendas. 8

The contentiousness of global health politics is nothing like the domestic politics of UHC or universal health care access by any other name. The US State Department has even objected to a World Health Organization fact sheet on the right to health. 9 Observation of politics in the United States, 10,11 or reading about the history of health politics anywhere, supports this point. UHC is expensive and redistributive; that is enough to make it contentious. 12,13 As if that were not enough, UHC also builds in additional contentious goals such as efficiency or access and medicines. 14–16 It is unwise to assume that UHC goals are entrenched in the countries that have broadly achieved them, to overstate the influence of health ministries or advocates committed to UHC, or to overstate the degree of consensus among governments that have adopted them on paper. 17,18

If any generalization about UHC holds, it is that democratization promotes it. Middle-income countries can broadly afford to aim for UHC, but they are most likely to enact access expansions when they have governments that are accountable to the population. 19–21 The effects of widespread democratization from the 1970s to the late 1990s help to explain the expansion of UHC in middle-income countries today. 22–25 Authoritarian regimes, by contrast, are less responsive to the broad population, can discourage or repress organized challenges, and therefore often focus benefits on a narrower set of people who are part of the regime or who can threaten it (e.g., by striking or staging a military coup). The result has been the historical pattern of segmentation that southern Europe and Latin America have had to confront, in which a few crucial sets of workers (especially the public sector and key strategic industries) enjoy extensive health and other benefits and groups without the capacity to threaten the regime receive less. 19,26–28

Partisan politics are one of the most promising avenues for explaining UHC. In particular, left-wing parties are more likely to enact redistributive policies such as UHC. 27,29–31 Socialist parties enacted universal health care across southern Europe when they came to power after democratization, 32 despite major recessions that might be expected to block health access expansion, and later it was the left that universalized health care in Latin American countries such as Brazil and Chile. 33,34 Conservative parties have also at times expanded health coverage for their own political purposes. 20,35 Otto von Bismarck created the first social health insurance in response to socialist challenges, Japan’s health insurance expansion came about as a response to a left labor challenge to the dominant conservative Liberal Democratic Party, and the expansion of health care access in Mexico was partly a strategy to maintain the popularity of its once-dominant Party of the Institutional Revolution. 36,37

Democracy and partisanship do not automatically produce UHC; UHC still needs organized support and faces organized opposition. 38–40 Unorganized voters are unlikely to have their preferences reflected in any political system. The complexities of organization, political coalitions, and parties, a long-standing issue in comparative politics, therefore demand attention; the relationship between left-party success and UHC policies is not simple, 31 and part of the reason is the interaction between politics and governance.

“Good governance” is a widely supported goal, but there is great disagreement about what it is and how it is to be attained. 41,42 Governance discussion often mixes governance as a phenomenon (how decisions are made) with normative policy advice (how decisions should be made and implemented, i.e., good governance). Governance as a phenomenon is the institutional framework of the decisions and policy implementation. 43 A review of components of governance in the health and broader policy literatures by authors associated with the European Observatory on Health Systems and Policies found that diverse authors focused on the same five areas in which governance can affect health systems: transparency, participation, accountability, integrity (management and anticorruption measures), and policymaking capacity. 44

Governance shapes the likelihood that UHC will be adopted and actually implemented for three reasons. First, it is a prerequisite for some policies. Just as policies for UHC can cost too much for a given state, they can also demand a level of expertise, accountability, and good public administration that is not always available. In particular, elaborate public–private, market-based, and personal insurance schemes can overwhelm the capacity to design, regulate, and operate them. 44

Second, governance, particularly political institutions, can shape the likelihood of pro-UHC forces winning in politics. Veto points at which a policy can be blocked include bicameralism, referenda, strong supreme courts, and some forms of federalism; they are correlated with slower increases of expenditure, less redistribution, and less programmatic coherence, although they also slow retrenchment. 29 Among the rich countries, the United States and Switzerland stand out for the expense, slow development, and inegalitarianism of their health systems and for their particularly high number of veto points. Their many veto points make opposition easier, demand larger political coalitions, and allow interest groups to extract a higher price for their support. 45–48

Third, governance affects the likelihood that programs will be entrenched by affording programs greater or lesser real effectiveness and greater or lesser political defenses. Although the post-Communist states have shown that it is politically very difficult to take away UHC, 19 their experiences also show that a system that only formally delivers UHC can engender effective privatization through exit from the system (into private provision) or informal payments. Ineffective programs engender less loyalty. Alternatively, governments can lock in UHC achievements by making the systems transparent and accountable to affected groups who will in the future be able to ward off efforts to reduce government commitments or undermine achievements. 49 A well-crafted policy includes governance changes that promote its own political survival by biasing policymaking toward groups who defend UHC. Just as Latin American's military regimes left institutional safeguards for their interests, 50 UHC advocates should pay attention to ways they can create institutional safeguards for a right to health. “Policies create politics,” after all. 51

CONCLUSIONS

There is a strong tendency to discuss UHC as though it were a settled goal that only requires technical follow-up. This approach contradicts or at least underplays a large body of evidence suggesting that UHC is potentially transformative and intensely political, and depends on the features of a country’s governance. Without support in domestic politics, a redistributive policy such as UHC is unlikely to happen. Without political support in the international arena, it can be undermined by advocates of other attractive goals such as programs focused on single diseases. Decision-making and implementation—governance—can support or hinder UHC advocates and deserve attention for the ways in which they can bias decisions and improve or hinder implementation.

For researchers, this means that we need to apply ourselves to better understanding the mechanisms connecting governance, political forces, and UHC decisions; although studies have pointed to the interplay of parties and institutions under democratization, much still remains to be understood about the coalitions and political strategies that shape UHC politics. For UHC advocates, this means that technical skills and advice should be regarded as resources to be used in what are ultimately political fights within countries, that the commitment to UHC by member states is a resource for political argument rather than a binding obligation, and that attention to health governance should come with an explicit objective of strengthening those who seek UHC.

Human Participant Protection

No protocol approval was necessary because this work was not considered human participant research.

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7 Strong Arguments For Why America Should Have Universal Healthcare

With COVID-19 still running its course and no end in sight, the integrity of American healthcare has never been more important. Is the current system truly the best the United States can do for its citizens? Or is socialized medicine a better alternative? Here are seven strong arguments for universal healthcare in America.

1. Lower Overall Costs

The costs of universal healthcare are far lower in other Western countries than private coverage in the United States. For example, administrative expenses alone make up 8% of the nation’s total healthcare costs . On the other hand, other developed countries with universal care don’t reach any higher than 3%.

What’s more, many Americans don’t seek the care they need because the cost of one visit can bankrupt them. Compared to other countries, prices for vital medicine, such as insulin, are sky-high in the United States. Universal healthcare guarantees service to everyone, no matter their financial status. When medical care isn’t such a financial strain, citizens can prioritize their health and seek the treatment they need.

2. Greater Hospital-Patient Trust

One disturbing reason American healthcare is so expensive is the trend of surprise billing. A routine surgery or treatment can cost thousands of dollars more than expected due to additional vague charges. You can even face a hefty fee just for sitting in a waiting room. The U.S. government has made some efforts to fix this problem , but private medical facilities have managed to find loopholes in the legislation.

Universal healthcare takes the billing power away from these facilities, creating more trust between hospital and patient: Payment comes in the form of taxes. While nobody likes to pay more taxes, it’s fairer to pay a fixed amount every year than receive a debilitating hospital bill after one visit.

3. Better Quality Care

The quality of treatment under socialized medicine seems to work better for its citizens than America’s privatized system. Infant mortality rates are lower, average life expectancy is higher and fewer people die from medical malpractice, which happens to be the third-leading cause of death in the United States. 

America also has obesity and cardiovascular disease epidemic, which fills up hospitals and leads to many preventable deaths. Comparable countries with universal healthcare have much lower mortality rates. This is because these nations promote more healthy lifestyles , easing the workload on hospitals and opening up space for people who need urgent care. 

4. More Coverage

Americans rely on their insurance companies to pay for their medical bills, but insurance doesn’t cover every injury or sickness. As you might expect, many citizens go bankrupt from hospital expenses. In contrast, universal healthcare covers any medical issue that might happen to a citizen. So patients don’t need to worry about any loopholes or caveats in their insurance coverage.

5. Shorter Wait Times

Perhaps the biggest criticism of universal healthcare is the extended wait times, but Americans already have long waits. COVID-19 patients are filling up waiting rooms and hospital beds. Because of that, many doctors have begun to hold virtual appointments for patients who can’t see them in person. Still, this solution has only put a dent in the problem. 

Patients under a universal system don’t have to wait for their insurance’s approval before seeking the care they need.

6. Greater Mobility

Since Americans often have to pay their own medical bills, they might feel pressured to keep unfulfilling jobs just for the insurance coverage. So in an ironic twist, they’re forced to put work over their health and well-being just so they can afford healthcare.

Universal healthcare allows you to change jobs without losing coverage. The current privatized system doesn’t embody American values of freedom and liberty. Rather, it restricts their life choices and access to care.

7. Coverage for the Uninsured

Insured citizens at least have access to some healthcare coverage, but the uninsured are entirely on their own. A large percentage of the uninsured have little to no disposable income, and they can’t afford the coverage they need.

Some evidence also suggests that uninsured patients wait longer and receive poorer care than more financially stable patients. As a result, the uninsured have an excess mortality rate of 25% , according to the Institute of Medicine. This negligence is unacceptable and largely avoidable. A universal healthcare system provides its people with care regardless of their insurance status.

America needs universal healthcare. The United States’ private healthcare system has too many glaring flaws to justify its existence. Adopting a universal plan would grant more cost-effective coverage to everyone, including the millions of people who currently can’t afford treatment. A more efficient and trustworthy system would help Americans exercise their fundamental rights to life, liberty, and the pursuit of happiness.

Featured image via CDC on Unsplash

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