Universal Health Care Across the Globe: A Series | Preface
As the Democratic presidential primary race gets under way, there is going to be a great policy debate on health care, which some ideologues will try to subvert to claim that only a certain kind of plan (from their candidate) will suffice. Several Democrats running have embraced the idea of Medicare for All, a single-payer health care system. But beyond that, details from different candidates will emerge differently. Some candidates, most notably Sen. Amy Klobuchar (D-MN), have declined to endorse Medicare for All as the only possible remedy in the immediate term, though Klobuchar has described it as something that could happen int he future.
As the candidates continue to detail their plans on health care, I plan on covering them in detail on TPV.
A key - and correct - argument in favor of universal health care is that many countries have achieved some form of it, and it does not make any sense for the richest nation on earth not to. But this is where ideologues stop their argument, often with the assumption - or at least the impression - that all countries with universal coverage have essentially the same system, and furthermore, that it is the system their candidate is proposing. This is particularly prominent among Bernie Sanders’ most rigid fans, who have made it a religion that the only true form of universal health care coverage is through single payer.
This is, of course, not true. For one thing, single payer itself has many forms and is not one thing, as most activists who do not have to write legislation imagine. But more importantly, countries across the globe have achieved some form of universal coverage in different ways: some through regulating insurance companies and individual and business mandates (very much like Obamacare), some through a mix of public and private coverage, and some have achieved it through forms of single payer and socialized medicine. In fact, according to one list of countries with universal coverage, just half have a single-payer system.
So as the policy debate ensues on health care, I believe it will be useful for us to explore the different universal health care systems, what and they cover, how they are paid for, and the role of government in each system. That is what this series will be all about. I will focus the series mostly on non-single payer systems, not because I dislike single payer, but because that is the system people mistake as synonymous for universal coverage, and one goal of this series will be to break that false impression.
But before we begin such a series, it is important to understand a few important concepts.
WHAT IS COVERAGE?
Commonly, the use of the phrase ‘universal coverage’ focuses on a population being covered, rather than conditions being covered, or whether everyone has access to the same, or even a minimum, quality of coverage. For example, most lists of universal coverage include systems that cover broken bones but neglect mental health. They include systems that cover childbirth but not abortions. As we explore the systems in different countries, we will be paying special attention to key progressive health care values, like addiction treatment, the right to abortion as health care, mental health parity, gender reassignment treatment, cultural competence, and quality of care for minorities, women, and the poor.
WHAT IS UNIVERSAL/WHO IS COVERED?
Under the definitions many lists tend to use, coverage is ‘universal’ even if it only covers the citizens or citizens and legal immigrants. In fact, countries like England would fit this category. What we as Democrats consider “universal” is an important question that needs to be answered.
COST, USE, OUTCOMES
A system can be universal and yet fail to deliver outcomes, especially to vulnerable populations. Is that system any good or even truly universal? The United States is known for its high health expenditures, so it would be proper to examine the costs of other systems, have some ideas on how they contain cost, and the use of the health care system by those who benefit from it.
When all is said and done, I think that we will learn from these systems that America’s challenges have many things in common with other countries, but that we also face unique challenges.
It has been a longstanding tradition in American healthcare legislation, for example, to insert a provision that says federal dollars will not pay for abortions. Known as the “Hyde amendment,” it prevents programs like Medicare and the VA from paying for or providing abortion services. If the United States is to implement a single payer system, and the payer is the federal government, then the preservation of the Hyde amendment combined with Medicare for All would actually mean the end of a meaningful right to abortion, the end of Roe v. Wade. How do we solve that? If we can eradicate this ridiculous “principle”, then how do we stop the universal coverage debate from devolving into the “OMG gubmint abortions!” debate?
Recall that the Affordable Care Act required 60 votes in the Senate, and even as the Democrats at the time had 60 senators in our caucus, it was nearly impossible to pass it through that chamber, Hyde Amendment and all. Democrats are not likely to have 60 seats in the Senate in the next Congress, let alone have 60 senators agree to lift the ban on abortion funding when anti-abortion Democratic senators are accounted for.
There are other unique challenges like national ID as well. Many countries with single payer health systems use some form of national ID, at least for their health care systems. A national ID, it should be noted, collects more data than our social security system, and of course, not every resident of the United States even has a social security card. Influential civil rights organizations like the ACLU have opposed the creation of a national ID for the purpose of employment. Will they - and the American public - be more amenable to creating one for health care? Why? If not, will states essentially be charged with the responsibility to handle the systems? If so, how do we stop right wing legislatures and governors from disrupting the system the way they did Obamacare?
Like it or not, America has to answer questions most - if not all - other nations do not, because of our current systems of laws, division of powers, and values.
My hypothesis is that the practical American system of universal coverage will need to be closer to a mix of traditional Medicare, Medicaid, Medicare/Medicaid buy-in or a public option, and highly regulated private insurance, along with mandates - call it Obamacare on steroids - than what is traditionally understood to be a single-payer government run program.
With that, stay tuned for the series and find out if my hypothesis actually turns out to be correct. Oh, and get your nerd hats on.
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