tag:theconversation.com,2011:/us/topics/universal-coverage-38637/articlesUniversal coverage – The Conversation2022-01-14T16:37:59Ztag:theconversation.com,2011:article/1747462022-01-14T16:37:59Z2022-01-14T16:37:59ZWhy lowering everyone’s energy bills is a better solution than targeting only the most vulnerable<figure><img src="https://images.theconversation.com/files/440853/original/file-20220114-15-1iga1fh.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/E31OyLefPTs">Vitolda Klein/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Energy bills will rise by <a href="https://www.bbc.co.uk/news/business-59760331">as much as 50%</a> from April 2022 unless the government intervenes, as Britain’s energy regulator Ofgem is expected to raise its price cap. Many households face a cost of living crisis and dramatically increased fuel poverty.</p>
<p>Most political parties <a href="https://www.bbc.co.uk/news/uk-politics-59935555">agree</a> that the government will need to step in to shelter consumers from this expected price rise. There is also widespread agreement in Westminster that financial support, such as expanding the <a href="https://www.gov.uk/the-warm-home-discount-scheme">Warm Home Discount</a>, should be especially focused on those who are most in need.</p>
<p>On the surface, this seems sensible. But attempting to target relief measures in this way could actually exclude some of the most vulnerable people. The best way to ensure help reaches everyone who needs it is through universal approaches that seek to lower energy bills for all.</p>
<h2>Who counts as vulnerable?</h2>
<p>Targeting support means defining a section of the population who are eligible for assistance. Despite appearing straightforward, this is actually very difficult. It demands a subjective (and often political) judgement about who counts as genuinely in need.</p>
<p>Take the relevant example of fuel poverty. In England, the official definition of a fuel poor household was changed <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/211135/government_response_fuel_poverty_consultation.pdf">in 2013</a> and again <a href="https://www.gov.uk/government/publications/sustainable-warmth-protecting-vulnerable-households-in-england">in 2021</a> – ostensibly to <a href="https://doi.org/10.1177/0261018316674851">better target support</a>. The devolved nations have maintained the older definition <a href="https://www.eas.org.uk/en/fuel-poverty-across-the-uk_50535/">used in England before 2013</a>.</p>
<p>Altering the definition produces starkly different profiles of <a href="https://doi.org/10.1016/j.erss.2017.09.035">who is vulnerable</a> and so deemed deserving of help by targeted support schemes. The older definition emphasises rural households reliant on expensive oil heating, while a newer one draws attention to those living in energy inefficient urban housing. <a href="https://doi.org/10.1177/1420326X17718054">Neither indicator</a> is categorically better. Instead, each one reveals certain forms of vulnerability, <a href="https://doi.org/10.1177/0308518X18764121">while hiding others</a>.</p>
<p>However the vulnerable are defined, narrowly targeting financial support invariably excludes people experiencing hardship who, under another definition, would be eligible for help. And even if a definition could be agreed upon, there are further issues with means-tested approaches.</p>
<p>Accurately identifying and reaching people entitled to assistance is often limited by incomplete or unavailable data. Efforts to target support also tend to rely on people applying for it, but many don’t. For example, only about 60% of UK households entitled to the Pension Credit <a href="https://www.gov.uk/government/statistics/income-related-benefits-estimates-of-take-up-financial-year-2018-to-2019/income-related-benefits-estimates-of-take-up-financial-year-2018-to-2019">receive the benefit</a>. People may not apply for a host of reasons: <a href="https://www.citizensadvice.org.uk/Global/CitizensAdvice/Energy/Final%20-%20modernising%20consumer%20support%20in%20essential%20markets.pdf">complex and confusing</a> application processes, limited knowledge of entitlements, <a href="https://raceequalityfoundation.org.uk/wp-content/uploads/2017/11/Better-Housing-27-Universal-Credit.pdf">language barriers</a>, or limited access to the <a href="https://www.cas.org.uk/system/files/publications/vff_online_barriers_to_maintaining_uc_claims_0.pdf">internet and computers</a>. Often, those who fail to apply are among the most marginalised sectors of society.</p>
<p>Being identified as in need and targeted for special assistance can also be <a href="https://doi.org/10.1016/j.socscimed.2006.01.012">stigmatising</a>. This <a href="https://www.researchgate.net/publication/322315936_EVALUATE_project_policy_brief_no_4_Qualitative_findings">puts people off</a> applying for help even when they really need it. One British study found one in four people <a href="https://www.turn2us.org.uk/T2UWebsite/media/Documents/Benefits-Stigma-in-Britain.pdf">delayed or avoided claiming</a> means-tested benefits due to the stigma attached to it.</p>
<p>A common argument for stringent targeting is that it enables public money to be spent more cost-effectively. But often the savings are much less than anticipated, because means-testing requires significant <a href="https://www.theguardian.com/social-care-network/2013/jan/14/means-testing-benefits-not-efficient-fair">additional bureaucracy</a>.</p>
<h2>The alternatives</h2>
<p>Compared to targeted approaches, universal social assistance schemes are <a href="https://ideas4development.org/en/social-protection-universal-provision-is-more-effective-than-poverty-targeting/">superior</a> at reaching those in hardship. They avoid the difficult task of defining a vulnerable population and remove the barriers, complexity <a href="https://doi.org/10.1177/0010414006295234">and stigma</a> that prevent people accessing support. So, although universal measures can be more expensive, they are also much more effective and inclusive.</p>
<p>There is no single solution to rising energy costs, but a range of policies could reduce bills for everyone, now and in the future.</p>
<p>Subsidies for building more renewable energy installations like wind farms and making homes more energy efficient are essential for tackling climate change and fuel poverty. But funding these through taxation rather than levies on energy bills – as is currently the case <a href="https://www.cityam.com/treasury-considers-cutting-green-levy-to-ease-cost-of-living-crisis-for-uk-households/">in the UK</a> – would reduce bills by around <a href="https://www.newscientist.com/article/2303699-energy-crisis-what-can-the-uk-government-do-to-help-cut-fuel-bills/">£160 per year</a>. It would also be fairer, because higher earners <a href="https://www.jrf.org.uk/sites/default/files/jrf/migrated/files/fuel-poverty-policy-summary.pdf">would pay proportionally more</a>.</p>
<p>Removing VAT from energy bills would save <a href="https://www.newscientist.com/article/2303699-energy-crisis-what-can-the-uk-government-do-to-help-cut-fuel-bills/">a further £90 per year</a>. Another option is to provide government loans to energy suppliers to cover the costs of wholesale gas price rises, potentially lowering bills by <a href="https://www.cornwall-insight.com/wp-content/uploads/2021/12/Options-for-suppliers.pdf">about £500 per year</a>.</p>
<p>There may well be a place for some degree of targeted financial support, but this should be as a supplement, rather than a replacement, for universal measures. And ultimately, much more needs to be done to tackle the root causes of fuel poverty and rising energy costs. This means significant investment in energy efficiency to <a href="https://www.theccc.org.uk/publication/uk-housing-fit-for-the-future/">fix the UK’s leaky housing stock</a>, and rapidly deploying renewable energy and low-carbon heating to reduce our reliance on expensive and volatile gas supplies.</p>
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<img alt="Imagine weekly climate newsletter" src="https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434988/original/file-20211201-21-13avx6y.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p class="fine-print"><em><span>Neil Simcock receives funding from UK Research and Innovation through the Centre for Research into Energy Demand Solutions, grant reference number EP/R035288/1. He also receives funding from the Royal Geographical Society (with IBG), and is a member of Energy Action Scotland. The views expressed in this article are his own and do not necessarily reflect the views of these funders or organisations.</span></em></p>Means-testing support for fuel-poor households will leave millions in hardship.Neil Simcock, Lecturer in Human Geography, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1296712020-01-14T13:47:28Z2020-01-14T13:47:28ZHeading into Iowa: Where do the Democratic candidates stand on health care coverage?<figure><img src="https://images.theconversation.com/files/309785/original/file-20200113-103994-p61eqr.jpg?ixlib=rb-1.1.0&rect=15%2C309%2C5281%2C3168&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Joe Biden, Elizabeth Warren and Pete Buttigeig at the Oct. 15, 2019 debate at Otterbein University in Westerville, Ohio. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-Election-2020-Debate/369ab17a3a09469eba384c5e3e0b2e3c/16/0">John Minchillo/AP Photo</a></span></figcaption></figure><p>As Democratic presidential hopefuls gather in Iowa for the seventh debate, Iran and foreign policy will likely play a central role. </p>
<p>But health care will remain the most important topic of debate for many Americans. No doubt, all six candidates tonight will talk about their proposals for health health reform using terms like universal coverage, public option, “Medicare for All,” and single-payer. </p>
<p>What do these terms mean, and where do Democratic presidential candidates onstage in Iowa stand on expanding coverage to all Americans?</p>
<h2>First things first: Who should be covered?</h2>
<p>Most Western nations ensure that everyone living in their country has access to insurance coverage. This is referred to as <a href="https://theconversation.com/universal-coverage-single-payer-medicare-for-all-what-does-it-all-mean-for-you-128518">universal coverage</a>. </p>
<p>Generally, this <a href="https://www.who.int/health_financing/universal_coverage_definition/en/">coverage includes</a> access to all needed services and benefits while protecting individuals from excessive costs. </p>
<p>The <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">U.S. is an exception</a>. Even the <a href="https://doi.org/10.1111/j.1541-0072.2012.00446.x">Affordable Care Act</a> only created what’s called <a href="https://doi.org/10.1111/puar.12065">“near universal coverage</a>” leaving millions of American uninsured.</p>
<p>From a policy perspective, achieving universal coverage is a worthwhile goal. There is <a href="https://www.nytimes.com/2017/07/03/upshot/medicaid-worsens-your-health-thats-a-classic-misinterpretation-of-research.html">ample evidence</a> that insurance coverage generally <a href="https://theconversation.com/universal-coverage-single-payer-medicare-for-all-what-does-it-all-mean-for-you-128518">improves the health and financial security of individuals</a>. </p>
<p>There is no single pathway to universal coverage. Countries that have achieved it have done so in <a href="https://www.commonwealthfund.org/publications/other-publication/2018/dec/multinational-comparisons-health-systems-data-2018">different ways</a>. Democratic presidential candidates all agree that providing coverage to everyone is the ultimate goal. However, they differ widely on how – and how fast – to get there.</p>
<p><iframe id="DFoot" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DFoot/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Single-payer, all-payer and socialized medicine</h2>
<p>One way to get to universal coverage is to create a “<a href="http://www.milkenreview.org/articles/would-state-based-single-payer-health-insurance-cure-what-ails">single-payer system</a>.” This means that one entity, most likely the government, is solely and exclusively responsible for paying for medical goods and services. In short, paying for health care is socialized. </p>
<p>In reality, government is often the dominant but not sole payer and <a href="https://theconversation.com/universal-coverage-single-payer-medicare-for-all-what-does-it-all-mean-for-you-128518">allows for supplemental insurance or for individuals to pay for alternate or additional services</a>. A single-payer system could be confined to providing catastrophic coverage only while allowing for private coverage for additional benefits.</p>
<p>Advocates often hail single-payer systems for their <a href="http://www.milkenreview.org/articles/would-state-based-single-payer-health-insurance-cure-what-ails">administrative simplicity</a>. And single-payer systems <a href="https://doi.org/10.1515/for-2013-0056">do not segregate individuals</a> into different insurance coverage based on their medical status. Single-payer systems are able to use their absolute market and budgeting power to <a href="http://www.milkenreview.org/articles/would-state-based-single-payer-health-insurance-cure-what-ails">hold down costs</a>. </p>
<p>Single-payer systems should not be confused with so-called <a href="https://www.vox.com/2015/2/9/8001173/all-payer-rate-setting">all-payer systems, like those in Germany</a>. In all-payer systems, a number of private entities band together to establish common prices for health care services and benefits. Single-payer should also not be equated with <a href="https://doi.org/10.1215/03616878-7277356">socialized medicine</a>, a medical system wholly owned and operated by government, such as in the <a href="https://www.nhs.uk/">United Kingdom</a> and <a href="https://doi.org/10.1215/03616878-7277356">public hospitals, or the Veterans Health Administration in the U.S.</a> </p>
<p>Sens. Sanders and Warren strongly support converting the U.S. health care system to a single-payer system. All other candidates have shown more limited support without disavowing a single-payer systems as an ultimate destination for health reform.</p>
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<img alt="" src="https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Sen. Elizabeth Warren, D-Mass., and Sen. Bernie Sanders, I-Vt., unveiled their Medicare-for-All plan on Capitol Hill, Sept. 13, 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/00041bcb32ef4535b7ba3caa0a4155cf/4/0">Andrew Harnik/AP Photo</a></span>
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<h2>The progressives’ favorite: ‘Medicare for All’</h2>
<p>The most discussed Democratic health reform proposal, Medicare for All, prominently references <a href="https://doi.org/10.1177/2333392818824472">Medicare</a>, the insurance program that covers most of America’s seniors. Many people do not recognize, however, that traditional Medicare comes with <a href="https://theconversation.com/universal-coverage-single-payer-medicare-for-all-what-does-it-all-mean-for-you-128518">limited benefits and often requires large out-of-pocket payments</a>. </p>
<p>In essence then, Medicare for All proposals <a href="http://www.milkenreview.org/articles/life-and-politics-beyond-the-affordable-care-act">just borrow the Medicare name</a> while implementing a single-payer system in the United States with a generous benefits package. </p>
<p>As proposed by its two most ardent advocates, <a href="https://www.vox.com/2019/4/10/18304448/bernie-sanders-medicare-for-all">Sens. Bernie Sanders, I-Vt.,</a> and <a href="https://www.vox.com/2019/11/1/20942587/elizabeth-warren-medicare-for-all-taxes-explained">Elizabeth Warren, D-Mass.</a>, Medicare for All would eliminate all private insurance. It would be financed by taxes and come with very limited, if any, out-of-pocket costs.</p>
<p>One particular political stumbling block for implementing Medicare for All is that it makes the overall cost of health coverage an obvious focal point. That’s because it unifies all of the country’s exorbitant health expenditures, projected to be <a href="https://www.factcheck.org/2018/08/the-cost-of-medicare-for-all/">roughly US$60 trillion from 2022 to 2031</a>, in one single budget. This creates the perception of being overly costly, while <a href="https://www.factcheck.org/2018/08/the-cost-of-medicare-for-all/">mostly just illustrating current costs</a>. </p>
<p>Moreover, it would create a significant disruption in how Americans experience health insurance, with hundreds of millions of Americans having to give up their current insurance. Many of them would certainly be upset as the vast majority of them rate their insurance as <a href="https://news.gallup.com/poll/245195/americans-rate-healthcare-quite-positively.aspx">excellent or good</a>.</p>
<p>The four other candidates have cited these concerns extensively, saying that the systemic disruptions and lack of widespread political support would stymie a quick transition to Medicare for All. </p>
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<img alt="" src="https://images.theconversation.com/files/309799/original/file-20200113-103979-vvwttc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/309799/original/file-20200113-103979-vvwttc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/309799/original/file-20200113-103979-vvwttc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/309799/original/file-20200113-103979-vvwttc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/309799/original/file-20200113-103979-vvwttc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/309799/original/file-20200113-103979-vvwttc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/309799/original/file-20200113-103979-vvwttc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Democratic presidential candidates Amy Klobuchar, left, and Tom Steyer at the Dec. 19, 2019 debate in Los Angeles.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Election-2020-Debate/704f38b465a24e9a8406f00a02baf874/6/0">Chris Carlson/AP Photo</a></span>
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<h2>The moderates’ response: The public option</h2>
<p><a href="http://www.milkenreview.org/articles/life-and-politics-beyond-the-affordable-care-act">Not all Democrats</a> argue for such a complete do-over of the American health care system. </p>
<p>Most Democratic presidential candidates are supporting a further expansion of the Affordable Care Act. <a href="https://www.politico.com/story/2019/07/15/joe-biden-health-care-plan-1415850">Led by Joe Biden</a>, these proposals contain a <a href="https://theconversation.com/universal-coverage-single-payer-medicare-for-all-what-does-it-all-mean-for-you-128518">so-called public option</a> combined with a number of regulatory reforms. These proposals would largely retain the existing structure of the health care system and preserve a role for private insurance. </p>
<p>The term “<a href="https://doi.org/10.1377/hlthaff.2010.0363">public option</a>” first gained traction during <a href="https://doi.org/10.1111/j.1541-0072.2012.00446.x">the debate over the Affordable Care Act</a> in 2010. Then, progressive Democrats sought to include a government-run insurer in the <a href="https://doi.org/10.1215/03616878-2882219">ACA marketplaces</a>. Yet the latest <a href="https://www.politico.com/story/2019/07/15/joe-biden-health-care-plan-1415850">public option</a> concept is significantly more transformative than its ACA cousin. It would be open to every American, whether they purchase their own insurance or receive it from their employer. This public insurer would also use its market power to negotiate better prices. </p>
<p>Four Democratic candidates have come out strongly supporting a public option. These include Biden, former South Bend Mayor Pete Buttigieg, Sen. Amy Klobuchar, D-Minn., and Tom Steyer. </p>
<p>However, Warren has expressed <a href="https://www.vox.com/policy-and-politics/2019/11/15/20966674/elizabeth-warren-medicare-for-all-plan-public-option">support for a public option</a> during a transitional period to Medicare for All. Over time, the public option might <a href="https://www.vox.com/2019/7/16/20694598/joe-biden-health-care-plan-public-option">function as a bridge toward a single-payer system</a>. </p>
<p>While Democratic candidates largely break into two camps when it comes to health care reform, there is general consensus about the importance of providing affordable access to health care coverage. All candidates have come out strongly in support of protecting the Affordable Care Act until needed adjustments can be made.</p>
<h2>Comparison to Republican plans</h2>
<p>Almost 10 years after the ACA has been signed into law, a <a href="https://www.bloomberg.com/opinion/articles/2020-01-10/obamacare-medicaid-expansion-defies-republican-health-care-chaos-k58552bp">comprehensive Republican health reform proposal has failed to emerge</a>. Yet there remains little doubt that the Republican health reform would look dramatically different from Democrats. </p>
<p>While details remain sparse, any Republican reform would likely <a href="https://rsc-johnson.house.gov/news/press-releases/rsc-releases-health-care-plan">eliminate many of the coverage expansions of the ACA</a>. <a href="https://theconversation.com/how-undoing-obamacare-would-harm-more-than-the-health-of-americans-129177">Millions of Americans gained coverage</a> because they were allowed to stay on their parents’ health insurance until age 26. <a href="https://theconversation.com/how-undoing-obamacare-would-harm-more-than-the-health-of-americans-129177">Millions more</a> gained insurance because of the expansion of Medicaid or in the ACA marketplaces, often with the help of premium subsidies. </p>
<p>Republicans would likely also <a href="https://rsc-johnson.house.gov/news/press-releases/rsc-releases-health-care-plan">transform the Medicaid program,</a> which provides coverage to <a href="https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html">close to 70 million Americans</a>. They would do this by limiting the financial contribution of the federal government to Medicaid.</p>
<p>Finally, they would likely also <a href="https://rsc-johnson.house.gov/news/press-releases/rsc-releases-health-care-plan">undo many if not all of the insurance market reforms</a> of the ACA. They include, for example, guaranteed coverage of <a href="https://theconversation.com/how-pre-existing-conditions-became-front-and-center-in-health-care-vote-77138">pre-existing conditions</a> and the prohibition for insurance carriers to <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">impose annual and lifetime limits on benefits</a>.</p>
<p>With all the talk on both sides of reform, political realities make it likely that neither Republicans nor Democrats will have their way any time soon. </p>
<p>However, with <a href="https://theconversation.com/how-undoing-obamacare-would-harm-more-than-the-health-of-americans-129177">lawsuits continuing to threaten the ACA,</a> Americans could quickly find the current system, which <a href="https://www.kff.org/health-reform/poll-finding/6-charts-about-public-opinion-on-the-affordable-care-act/">most have come to support</a>, dismantled. And, of course this would entail a return to the system before the ACA – a system few would recognize and which could meet far fewer people’s health care coverage needs. </p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/129671/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder is a Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems.</span></em></p>Among the issues candidates will debate Tuesday night is health care – an important, yet confusing, topic for viewers. An expert simplifies, explaining where and what the candidates stand for.Simon F. Haeder, Assistant Professor of Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1285182020-01-07T13:13:04Z2020-01-07T13:13:04ZUniversal coverage, single-payer, ‘Medicare for All’: What does it all mean for you?<figure><img src="https://images.theconversation.com/files/307587/original/file-20191218-11909-18n5ui2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bill Clinton's 1993 health care plan called for universal coverage. It was dead by 1994, but the political wrangling it started over health care lives on. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Watchf-AP-A-DC-USA-APHS349841-President-Bill-Cl-/db66aa3d967e41348c972b7335b043a1/95/0">J. Scott Applewhite/AP Photo</a></span></figcaption></figure><p>Collectively, <a href="https://www.theatlantic.com/business/archive/2018/01/health-care-america-jobs/550079/">health care is our biggest industry</a>. And, health care has long been one of the <a href="https://doi.org/10.1017/S0898030615000330">most politically contested issues</a>. Partisan wrangling over health reform has perhaps been the most acrimonious issue in Americans politics, exemplified by the failed <a href="https://doi.org/10.1176/ps.45.9.871">Clinton health reform efforts</a> in the 1990s and the <a href="https://doi.org/10.1111/j.1541-0072.2012.00446.x">passage of the Affordable Care Act</a> in 2010.</p>
<p>Most <a href="https://www.healthcarefinancenews.com/news/americans-still-confused-about-healthcare-law-survey-finds">Americans are befuddled</a> by it, and the political debate surrounding it only <a href="https://theconversation.com/us-health-care-system-a-patchwork-that-no-one-likes-85252">makes it more confusing</a>. </p>
<p>You have no doubt heard these terms bandied about: Universal coverage, public option, “Medicare for All,” single-payer. What do these terms mean, and why do they matter going into the Presidential race in 2020? </p>
<h2>Universal coverage: Getting everyone covered</h2>
<p>Universal coverage refers to health care systems in which all individuals have insurance coverage. Generally, this <a href="https://www.who.int/health_financing/universal_coverage_definition/en/">coverage includes</a> access to all needed services and benefits while protecting individuals from excessive financial hardships. Most Western nations fall into this category. </p>
<p>The U.S. serves as the notable exception, with millions of Americans remaining uninsured. The Obama administration touted the passage of the <a href="https://doi.org/10.1111/j.1541-0072.2012.00446.x">Affordable Care Act</a> as a step toward <a href="https://doi.org/10.1111/puar.12065">“near universal coverage</a>.” This differs markedly from <a href="https://doi.org/10.1176/ps.45.9.871">Bill Clinton’s proposal in the 1990s</a> which made covering all Americans a centerpiece. </p>
<p>Practically, there is no single pathway to universal coverage. Countries that have achieved it have done so in <a href="https://www.commonwealthfund.org/publications/other-publication/2018/dec/multinational-comparisons-health-systems-data-2018">diverse ways</a>. This includes approaches ranging from private to public insurance and delivery systems, or hybrids of both.</p>
<p>From a policy perspective, achieving universal coverage is a worthwhile goal. There is <a href="https://www.nytimes.com/2017/07/03/upshot/medicaid-worsens-your-health-thats-a-classic-misinterpretation-of-research.html">ample evidence</a> that insurance coverage generally improves the health of individuals. Perhaps equally important, insurance coverage serves as an important protection from <a href="https://www.nytimes.com/2015/06/23/upshot/medical-insurance-is-good-for-financial-health-too.html">financial destitution</a>. </p>
<p>Yet, insurance coverage does not necessarily entail having access to health care services, since <a href="https://doi.org/10.1377/hlthaff.2019.00116">travel distances</a> or <a href="https://doi.org/10.1377/hlthaff.2015.1554">wait times</a> may impede care. Moreover, <a href="https://www.healthaffairs.org/do/10.1377/hblog20190603.704918/full/">regulatory loopholes</a> currently expose many individuals with insurance coverage to large out-of-pocket bills.</p>
<h2>Single-payer</h2>
<p>“Single-payer” refers to <a href="http://www.milkenreview.org/articles/would-state-based-single-payer-health-insurance-cure-what-ails">financing a health care system</a> by making one entity, most likely the government, solely and exclusively responsible for paying for medical goods and services. It is only the financing component that is necessarily socialized. Single-payer is not necessarily socialized medicine, a medical system wholly owned and operated by government. </p>
<p>Single-payer systems are often hailed by advocates for their <a href="http://www.milkenreview.org/articles/would-state-based-single-payer-health-insurance-cure-what-ails">administrative simplicity</a>. Moreover, single-payer systems include everyone in the <a href="https://doi.org/10.1515/for-2013-0056">same risk pool</a>. That is, there is no segregation of individuals based on their medical status. Crucially, single-payer systems are able to use their absolute market and budgeting power to <a href="http://www.milkenreview.org/articles/would-state-based-single-payer-health-insurance-cure-what-ails">hold down costs</a>. </p>
<p>Government is often the dominant but not sole payer. Even in the United Kingdom, whose <a href="https://www.nhs.uk/">National Health Service</a> is famously popular, <a href="https://www.theguardian.com/business/2017/jan/16/private-medical-insurance-sales-surge-health-nhs">private insurance coverage</a> and <a href="https://www.telegraph.co.uk/news/2018/08/11/numbers-going-private-surgery-soaring-nhs-rationing-deepens/">private pay options</a> are available. </p>
<p>Conceivably, a limited single-payer system could be confined to providing catastrophic coverage only. However, this would clearly restrict its ability to realize its full market power. </p>
<p>Finally, it is important to note that single-payer systems should not be confused with so-called <a href="https://www.vox.com/2015/2/9/8001173/all-payer-rate-setting">all-payer systems, like those in existence in Germany</a>. Here, a number of private entities band together to establish common prices for health care services and benefits.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307590/original/file-20191218-11914-jl2vxv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sen. Elizabeth Warren, D-Mass., and Sen. Bernie Sanders, I-Vt., unveiled their Medicare-for-All plan on Capitol Hill Sept. 13, 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Health-Overhaul/00041bcb32ef4535b7ba3caa0a4155cf/4/0">Andrew Harnik/AP Photo</a></span>
</figcaption>
</figure>
<h2>Medicare in name only: ‘Medicare for All’</h2>
<p>The most talked-about Democratic health reform proposal, Medicare for All, prominently references <a href="https://doi.org/10.1177/2333392818824472">Medicare</a>, the insurance program that covers most of America’s seniors. However, simply expanding Medicare to all Americans would lead to a <a href="http://www.milkenreview.org/articles/life-and-politics-beyond-the-affordable-care-act">rude awakening for most</a>. Traditional Medicare benefits are rather limited and often carry with them large out-of-pocket payments. </p>
<p>For example, <a href="https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/">Medicare</a> does not include dental and vision coverage. A premium-based prescription drug benefit was not included <a href="https://doi.org/10.1017/S0898030615000330">until 2003</a>. And it came with the <a href="https://www.kff.org/medicare/fact-sheet/an-overview-of-the-medicare-part-d-prescription-drug-benefit/">infamous Part D donut hole</a> that exposed many seniors to significant out-of-pocket costs for their prescription drugs. </p>
<p>In essence then, Medicare for All proposals <a href="http://www.milkenreview.org/articles/life-and-politics-beyond-the-affordable-care-act">just borrow the Medicare name</a> while implementing a single-payer system in the United States. As proposed by its two most ardent advocates, <a href="https://www.vox.com/2019/4/10/18304448/bernie-sanders-medicare-for-all">Senators Bernie Sanders, D-Vt.,</a> and <a href="https://www.vox.com/2019/11/1/20942587/elizabeth-warren-medicare-for-all-taxes-explained">Elizabeth Warren, D-Mass.</a>, Medicare for All would eliminate all private insurance. It would also come with a very generous benefit package, and very limited, if any, out-of-pocket costs.</p>
<p>One particular stumbling block for implementing Medicare for All is that it makes the overall cost of health coverage an obvious focal point. Of course, costs for expanded benefits and coverage expansions would increase expenditures as compared to the status quo. It would also like <a href="https://www.factcheck.org/2018/08/the-cost-of-medicare-for-all/">increase health care utilization</a>. </p>
<p>However, most detrimental from a politics perspective, Medicare for All unifies all of the country’s exorbitant health expenditures, <a href="https://www.factcheck.org/2018/08/the-cost-of-medicare-for-all/">roughly US$60 trillion from 2022 to 2031</a>, in one single budget. This creates the misperception of being overly costly, while mostly just illustrating current costs. It will also entail a major realignment of the health sector with potentially <a href="https://khn.org/news/analysis-a-health-care-overhaul-could-kill-2-million-jobs-and-thats-ok/">substantial job losses</a> particularly in the insurance sector. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307592/original/file-20191218-11896-dn576a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307592/original/file-20191218-11896-dn576a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307592/original/file-20191218-11896-dn576a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307592/original/file-20191218-11896-dn576a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307592/original/file-20191218-11896-dn576a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307592/original/file-20191218-11896-dn576a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307592/original/file-20191218-11896-dn576a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Former Vice President Joe Biden at a campaign rally in Mason City, Iowa, Dec. 3, 2019.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Election-2020-Joe-Biden/e5c201b1709549c992b177ecc4cec690/122/0">Charlie Neibergall/AP Photo</a></span>
</figcaption>
</figure>
<h2>Set for a comeback: The public option</h2>
<p><a href="http://www.milkenreview.org/articles/life-and-politics-beyond-the-affordable-care-act">Not all Democrats</a> are arguing for a do-over of the American health care system. Another set of presidential candidates are arguing for an expansion of the Affordable Care Act. <a href="https://www.politico.com/story/2019/07/15/joe-biden-health-care-plan-1415850">Led by former Vice President Joe Biden</a>, these proposals largely retain the existing structure of the health care system. </p>
<p>The proposals include the creation of a “<a href="https://doi.org/10.1377/hlthaff.2010.0363">public option</a>.” This type of approach first gained traction during <a href="https://doi.org/10.1111/j.1541-0072.2012.00446.x">the debate over the Affordable Care Act</a>. Then, Progressive Democrats sought to include a government-run insurer in the <a href="https://doi.org/10.1215/03616878-2882219">ACA marketplaces</a>. This government entity would have competed with regular insurers for customers based on <a href="https://doi.org/10.1377/hlthaff.2014.1406">price, providers and benefits</a> for those purchasing insurance on their own. </p>
<p>Yet the <a href="https://www.politico.com/story/2019/07/15/joe-biden-health-care-plan-1415850">Public Option 2.0</a> is significantly more progressive than its ACA cousin. It would be open to every American, whether they purchase their own insurance or receive it from their employer. This public insurer would also be using its market power to negotiate better prices. Over time, it would likely <a href="https://www.vox.com/2019/7/16/20694598/joe-biden-health-care-plan-public-option">also function as a wedge to conduct further and more progressive reforms</a>. A potential final outcome might be a single-payer system. </p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/128518/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder is Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems.</span></em></p>The US has been trying to reform its complicated health care system since 1993. In 2020, it continues to be one of the biggest and most complicated issues of the presidential campaign.Simon F. Haeder, Assistant Professor of Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1188952019-07-24T11:09:04Z2019-07-24T11:09:04ZUS health care: An industry too big to fail<p>As I spoke recently with colleagues at a conference in Florence, Italy about health care innovation, a fundamental truth resurfaced in my mind: the U.S. health care industry is just that. An industry, an economic force, Big Business, first and foremost. It is a vehicle for returns on investment first and the success of our society second.</p>
<p>This is critical to consider as <a href="https://www.nbcnews.com/politics/2020-election/democrats-duel-over-health-care-new-campaign-dust-n1030171">presidential candidates</a> unveil their health care plans. The candidates and the electorate seem to forget that health care in our country is a huge business.</p>
<p>Health care accounts for almost <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html">20% of GDP</a> and is a, if not the, job engine for the U.S. economy. The sector added <a href="https://www.bls.gov/careeroutlook/2017/data-on-display/projections-industry-sectors.htm?view_fullmuch">2.8 million jobs</a> between 2006 and 2016, higher than all other sectors, and the Bureau of Labor Statistics projects another <a href="https://www.bls.gov/ooh/healthcare/home.htm">18% growth in health sector jobs</a> between now and 2026. Big Business indeed.</p>
<p>This basic truth <a href="http://www.oecdbetterlifeindex.org/">separates us from every other nation</a> whose life expectancy, maternal and infant mortality or incidence of diabetes we’d like to replicate or, better still, outperform.</p>
<p>As politicians and the public they serve grapple with issues such as prescription drug prices, “surprise” medical bills and other health-related issues, I believe it critical that we better understand some of the less visible drivers of these costs so that any proposed solutions have a fighting chance to deflect the health cost curve downward. </p>
<p>As both associate chief medical officer for clinical integration and director of the center for health policy at the University of Virginia, I find that the tension between a profit-driven health care system and high costs occupies me every day.</p>
<h2>The power of the market</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/284368/original/file-20190716-173329-13qq2t3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prescription drug prices, like everything else in society, is market-driven.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-searching-web-internet-recruitment-health-336058883?src=LZ6aDSUkCWt60CcEZPSJ9A-1-53&studio=1">angellodeco/shutterstock.com</a></span>
</figcaption>
</figure>
<p>Housing prices are <a href="https://brainmates.com.au/brainrants/what-does-a-market-driven-product-really-mean/">market-driven</a>. Car prices are market-driven. Food prices are market-driven. </p>
<p>And so are health care services. That includes physician fees, prescription drug prices and non-prescription drug prices. So is the case for hospital administrator salaries and medical devices.</p>
<p>All of these goods or services are profit-seeking, and all are motivated to maximize profits and minimize the cost of doing business. All must adhere to sound business principles, or they will fail. None of them disclose their <a href="https://www.accountingtools.com/articles/2017/5/4/cost-driver">cost drivers</a>, or those things that increase prices. In other words, there are costs that are hidden to consumers that manifest in the final unit prices.</p>
<p>To my knowledge, no one has suggested that <a href="https://www.rolls-roycemotorcars.com/en-US/home.html">Rolls-Royce Motor Cars</a> should price its cars similarly to <a href="https://www.ford.com">Ford Motor Company</a>. The invisible hand of “the market” tells Rolls Royce and Ford what their vehicles are worth. </p>
<h2>Prescription drugs pricing has different rules</h2>
<p>Ford can (they won’t) tell you precisely how much each vehicle costs to produce, including all the component parts that they acquire from other firms. But this is not true of prescription drugs. How much a novel therapeutic costs to develop and bring to market is a proverbial black box. Companies don’t share those numbers. Researchers at the Tufts Center for the Study of Drug Development have estimated the costs to be as high as US$2.87 billion, but that <a href="https://www.managedcaremag.com/news/20170914/costs-bring-drug-market-remain-dispute">number has been hotly debated.</a></p>
<p>What we can reliably say is that it’s very expensive, and a drug company must produce new drugs to stay in business. The millions of research and development(R&D) dollars invested by Big Pharma has two aims. The first is to bring the “next big thing” to market. The second is to secure the almighty patent for it. </p>
<p>U.S. drug patents typically last <a href="https://www.drugpatentwatch.com/blog/how-long-do-drug-patents-last/">20 years</a>, but according to the legal services website <a href="https://www.upcounsel.com/how-long-does-a-drug-patent-last">Upcounsel.com</a>: “Due to the rigorous amount of testing that goes into a drug patent, many larger pharmaceutical companies file several patents on the same drug, aiming to extend the 20-year period and block generic competitors from producing the same drug.” As a result, drug firms have 30, 40-plus years to protect their investment from any competition and market forces to lower prices are not in play.</p>
<p>Here’s the hidden cost punchline: concurrently, several other drugs in their R&D pipelines fail along the way, resulting in significant <a href="https://www.pharmaceutical-technology.com/features/featurecounting-the-cost-of-failure-in-drug-development-5813046/">product-specific losses </a>. How is a poor firm to stay afloat? Simple, really. Build those costs and losses into the price of the successes. Next thing you know, insulin is nearly <a href="https://www.statnews.com/2019/02/19/no-generic-insulin-who-is-to-blame/">US$1,500 for a 20-milliliter vial</a>, when that same vial 15 years ago was about $157. </p>
<p>It’s actually a bit more complicated than that, but my point is that business principles drive drug prices because drug companies are businesses. Societal welfare is not the underlying use. This is most true in the U.S., where the public doesn’t purchase most of the pharmaceuticals – private individuals do, albeit through a third party, an insurer. The group purchasing power of 300 million Americans becomes the commercial power of markets. Prices go up.</p>
<h2>The cost of doing business, er, treating</h2>
<p>I hope that most people would agree that physicians provide a societal good. Whether it’s in the setting of a trusted health confidant, or the doctor whose hands are surgically stopping the bleeding from your spleen after that jerk cut you off on the highway, we physicians pride ourselves on being there for our patients, no matter what, insured or not. </p>
<p>Allow me to state two fundamental facts that often seem to elude patient and policymaker alike. They are inextricably linked, foundational to our national dialogue on health care costs and oft-ignored: physicians are among the highest earners in America, and we make our money from patients. Not from investment portfolios, or patents. Patients. </p>
<p>Like Ford or pharmaceutical giant Eli Lilly, physician practices also need to achieve a profit margin to remain in business. Similarly, there are hidden-to-consumer costs as well; in this case, education and training. Medical school is <a href="https://www.thebalance.com/average-cost-of-medical-school-4588236">the most expensive professional degree</a> money can buy in the U.S. The American Association of Medical Colleges reports that median indebtedness for U.S. medical schools was <a href="https://news.aamc.org/medical-education/article/7-ways-reduce-medical-school-debt/">$200,000.00 in 2018</a>, for the 75% of us who financed our educations rather than paying cash.<br>
Our “R&D” – that is, four years each of college and medical school, three to 11 years of post doctoral training costs – gets incorporated into our fees. They have to. Just like Ford Motors. Business 101: the cost of doing business must be factored into the price of the good or service. </p>
<p>For policymakers to meaningfully impact the rising costs of U.S. health care, from drugs to bills to and everything in between, they must decide if this is to remain an industry or truly become a social good. If we continue to treat and regulate health care as an industry, we should continue to expect <a href="https://theconversation.com/why-thousands-are-getting-hit-with-unexpected-medical-bills-117955">surprise bills</a> and expensive drugs. </p>
<p>It’s not personal, it’s just…business. The question before the U.S. is: business-as-usual, or shall we get busy charting a new way of achieving a healthy society? Personally and professionally, I prefer the latter.</p><img src="https://counter.theconversation.com/content/118895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Williams does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Presidential candidates have been proposing plans to expand health coverage, lower prescription drug costs and make hospital bills more transparent. But few get to the real problem. Here’s why.Michael Williams, Associate Chief Medical Officer for Clinical Integration; Associate Professor of Surgery and Director of the UVA Center for Health Policy, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/852522017-10-18T23:33:04Z2017-10-18T23:33:04ZUS health care system: A patchwork that no one likes<figure><img src="https://images.theconversation.com/files/189035/original/file-20171005-14904-1jsbs7s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Senator Majority Leader Mitch McConnell, considered a powerful dealmaker, failed to get the necessary votes to repeal and replace the Affordable Care Act. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Republicans-The-Abyss-Analysis/4ce0032bcb224804a6fa19ffe4c5679f/123/0">AP Photo/Andrew Harnik</a></span></figcaption></figure><p>Almost all parties agree that the health care system in the U.S., which is responsible for about <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html">17 percent of our GDP</a>, is badly broken. Soaring costs, low quality, insurance reimbursements and co-payments confusing even to experts, and an ever-growing gap between rich and poor are just some of the problems.</p>
<p>And yet, this broken system reflects <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">the country’s constitutional foundation and its political culture</a>. At the very core of both is a strong suspicion of governmental intervention and a disdain for concentrated power, paired with an exaltation of individual liberty and personal responsibility.</p>
<p>Translating this ideology into a modern state is a complex endeavor that often leads to constructs that resemble creations envisioned by Rube Goldberg. Perhaps nowhere else is this more obvious as in the American health care system. The result has been the creation of an uncoordinated, often inefficient, patchwork of programs that <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">does not cover everyone, is excessively costly and often provides low-quality care</a>. </p>
<p>The conflicts of the past linger into the present, as seen in the dozens of Republican unsuccessful <a href="http://onlinelibrary.wiley.com/doi/10.1111/puar.12065/full">attempts to repeal and replace</a> the Affordable Care Act, the Obama administration’s signature, if maligned, law. </p>
<p>More generally, ideologically, the country has failed to reach a consensus about the appropriate role of government in the provision of health care for its citizens. Politically, reforming any part of the health care system becomes a third rail. Yet practically, while often left unacknowledged, government involvement is ubiquitous. Indeed, over time, governments, at both the state and federal level, <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">have come to influence every component of the American health care system</a>.</p>
<h2>A fragmented ‘system’</h2>
<p>Governments have three major options to provide benefits. They can regulate the conduct of private entities, provide services directly or merely provide financing while having services provided by other entities. In the United States, state and federal governments rely on all three options.</p>
<p>Today, <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">half of all Americans</a> obtain their insurance through an employer. Depending on the nature of the arrangement, these are subject to an <a href="http://www.sciencedirect.com/science/article/pii/S0168851014002607">often complex web of state and federal regulations</a>.</p>
<p>However, over time, the federal government has taken on an ever-larger role in the regulation of insurance, most recently <a href="https://www.degruyter.com/view/j/for.2013.11.issue-3/for-2013-0056/for-2013-0056.xml">culminating with the passage of the Affordable Care Act</a> in 2010. The federal government also provides generous tax incentives to encourage the employer-sponsored provision of insurance at an annual cost <a href="http://www.taxpolicycenter.org/briefing-book/how-does-tax-exclusion-employer-sponsored-health-insurance-work">exceeding US$260 billion</a>.</p>
<p>Yet, even despite regulatory action and financial support, more than half of all Americans are not covered through employer-sponsored insurance, thus requiring other, more active forms of government involvement.</p>
<h2>Different plans for the old, the poor and veterans</h2>
<p>Elderly Americans and some of those afflicted with disabilities and end-stage renal disease, about <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">14 percent of the population</a>, are covered by a purely federal, social insurance, single-payer arrangement, <a href="https://www.cms.gov/Medicare/Medicare.html">Medicare</a>. </p>
<p>Antiquated in its design because it separates hospital coverage from physician coverage, all <a href="https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html">working-age Americans are required to pay into the system that entitles them to hospital insurance at age 65</a>. <a href="https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html">Voluntary physician and prescription drug coverage</a> are subject to a combination of individual premiums and government subsidies. Many elderly choose to <a href="https://www.medicare.gov/supplement-other-insurance/medigap/whats-medigap.html">buy additional insurance</a> protection to make up for the often limited benefits under these programs. Alternatively, eligible individuals can choose to obtain comprehensive coverage through private insurers in a program called <a href="https://www.medicarefaq.com/original-medicare/medicare-parts/medicare-part-c/medicare-advantage-plan-types/">Medicare Advantage</a>.</p>
<p>Coverage for the poor and near-poor has been established through a joint state-federal program called <a href="https://theconversation.com/not-just-for-the-poor-the-crucial-role-of-medicaid-in-americas-health-care-system-78582">Medicaid</a>, providing coverage for <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">almost 20 percent of Americans</a>. Lacking the constitutional power to force states into action, the federal government necessarily seeks to <a href="http://jhppl.dukejournals.org/content/40/2/281.short">entice states into cooperation by shouldering a majority of the cost and allowing states broad authority</a> in structuring their individual programs. As a result, <a href="http://jhppl.dukejournals.org/content/40/2/281.short">programs vary significantly across the states</a> in terms of who is eligible and what benefits they have access to.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=440&fit=crop&dpr=1 754w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=440&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/190679/original/file-20171017-30417-1q08z8q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=440&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A veterans hospital in Ann Arbor, Michigan.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=95raD-KyAxJLNJdCqKEVTw-1-6">Susan Montgomery/Shutterstock.com</a></span>
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<p>One peculiar exception is the way America provides health care to its <a href="https://www.va.gov/health/">veterans</a>. Inherently ironic, in an arrangement that can only be described as socialistic, America’s veterans are able to obtain access to comprehensive services, often at no cost, through a national network of clinics and hospitals fully owned and operated by the federal government. Similar arrangements are in place for <a href="https://www.ihs.gov/">Native Americans</a>.</p>
<p>Those left out of the <a href="https://search.proquest.com/openview/acb042605925be5851f59fba137301ed/1?pq-origsite=gscholar&cbl=18750&diss=y">various, decidedly limited, arrangements are left</a> to seek coverage on their own from private insurers. Indeed, with the insurance market reforms and financial support of the ACA, today about <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">7 percent of Americans</a> are able to purchase insurance privately, while <a href="https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">9 percent remain uninsured</a>. Another patchwork of programs seeks to provide decidedly limited benefits to these individuals including through <a href="https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/">emergency rooms</a>, <a href="https://search.proquest.com/openview/acb042605925be5851f59fba137301ed/1?pq-origsite=gscholar&cbl=18750&diss=y">government-supported</a> private community health centers and hundreds of clinics and hospitals owned by cities, counties, states and state-university systems.</p>
<h2>Has the ACA changed anything?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/190680/original/file-20171017-30390-t0coi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A woman shows her support for the Affordable Care Act at a 2017 rally in Asheville, North Carolina.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asheville-north-carolina-usa-february-25-645796120?src=3tJorM5k1R6WjRe1GePMpA-1-43">J. Bicking/Shutterstock.com</a></span>
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<p>When the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1541-0072.2012.00446.x/full">ACA was passed in 2010</a>, supporters hailed it for moving the United States in line with its industrialized peers. <a href="http://www.nationalreview.com/article/418322/obamacare-horror-story-young-americans-diana-furchtgott-roth-jared-meyer">Detractors demonized</a> it by saying it was the final step toward socialism in America. </p>
<p>Neither side was <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">correct in its assessment</a>.</p>
<p>Within the American system, particularly as it has been used to expand access to health care, the ACA was a very substantial, but nonetheless natural, continuation of a long series of <a href="https://www.cambridge.org/core/journals/journal-of-policy-history/article/inching-toward-universal-coverage-statefederal-healthcare-programs-in-historical-perspective/E94A03DD1F60F9DCBE3DDE9728DA3224">incremental, trial-and-error adjustments to new circumstances hailing back to the early 1900s</a>. For the most part, the ACA perpetuates a system patched together from various private and public components by merely pairing some, albeit important, insurance market reforms with additional funding.</p>
<p>With regard to <a href="http://jhppl.dukejournals.org/content/40/2/281.short">Medicaid</a>, it simply added more, mostly federal, funding to bring more individuals into the program. For those <a href="http://jhppl.dukejournals.org/content/40/2/281.short">buying insurance on their own</a>, it facilitated purchasing insurance by establishing online marketplaces and by providing funding for lower-income individuals in the form of <a href="http://jhppl.dukejournals.org/content/40/2/281.short">subsidies for premiums and out-of-pocket costs</a>. Most importantly, it initiates meaningful insurance market reforms intended to facilitate access including the requirement to provide insurance <a href="http://jhppl.dukejournals.org/content/40/2/281.short">regardless of preexisting conditions</a>, by limiting how much consumer could be charged based on gender and age, and by requiring a minimum amount of services included, among others.</p>
<p>Yet even if the ACA were to be fully implemented, millions of Americans will be left without insurance, and the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1541-0072.2012.00446.x/full">thorny issues of quality and costs</a> will largely be left untouched.</p>
<h2>The future is…uncertain</h2>
<p>The American health care system is a complex amalgam. <a href="http://jhppl.dukejournals.org/content/40/2/281.short">Evolving over time</a>, we can see incremental, haphazard adjustments to changing circumstances over time, without much rationality or overarching forethought.</p>
<p>Conceptually, one can easily imagine a simpler approach. For example, the U.S. could adopt a single-payer system similar to those in many other wealthy industrialized countries. Practically, however, limited national authority, stark ideological divisions over the appropriate role of the national government in the provision of health care, and the creation of vested interests make other than a continued evolutionary approach politically unlikely, if not wholly implausible.</p>
<p>In such a system, exploiting the shortcomings of the American health care system and blaming it on the other party becomes a political imperative. No one party alone can truly reform the system by itself without risking the wrath of the electorate. Indeed, no underlying ideological consensus even exists about what kind of health care system the United States should have. </p>
<p>Under these conditions, neither party has much incentive to cooperate to initiate the <a href="https://theconversation.com/how-the-latest-effort-to-repeal-obamacare-would-affect-millions-84317">meaningful reforms necessary to improve quality, access and costs</a>. Thus, we are left with a system that is excessively costly and often of inferior quality that denies millions of American from accessing adequate care.</p><img src="https://counter.theconversation.com/content/85252/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon F. Haeder does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many Western, industrialized nations provide health insurance. The US has repeatedly balked at universal coverage. So what kind of system are we left with? A very unpopular one.Simon F. Haeder, Assistant Professor of Public Policy, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/775912017-05-15T00:07:33Z2017-05-15T00:07:33ZWhy the US does not have universal health care, while many other countries do<figure><img src="https://images.theconversation.com/files/169006/original/file-20170511-32613-edj2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">House Speaker Paul Ryan walking into the Capitol on May 4, when the House voted narrowly to accept a bill he shepherded to replace Obamacare. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Congress-Rdp/42feb4969aa84e64ae1345633357a69d/39/0">Andrew Harnik/AP</a></span></figcaption></figure><p>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. </p>
<p>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, <a href="https://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/">most advanced industrialized countries</a> have universal health care. </p>
<p>As a health policy and politics scholar, I have some ideas. Research from political science and health services points to three explanations. </p>
<h2>No. 1: American culture is unique</h2>
<p>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 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447684/">more likely to be individualistic</a>.</p>
<p>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.</p>
<p>Public opinion certainly supports this idea. Survey research conducted by the <a href="https://www.cambridge.org/core/journals/perspectives-on-politics/article/the-welfare-state-nobody-knows-debunking-myths-about-us-social-policy-and-welfare-discipline-discourse-governance-and-globalization-/5DB1392868DF638547F11B74EF111474">International Social Survey Program</a> 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.</p>
<h2>No. 2: Interest groups don’t want it</h2>
<p>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, <a href="https://www.publicintegrity.org/2010/02/24/2725/lobbyists-swarm-capitol-influence-health-reform">generated US$1.2 billion in lobbying</a> in 2009 alone.</p>
<p>The insurance industry was a key player in this process, spending over <a href="https://www.publicintegrity.org/2010/02/24/2725/lobbyists-swarm-capitol-influence-health-reform">$100 million to help shape the ACA</a> and keep private insurers, as opposed to the government, as the key cog in American health care.</p>
<p>While recent reports suggest <a href="http://www.cbsnews.com/news/doctors-health-groups-denounce-ahca-health-care-vote/">strong opposition from interest groups</a> 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. </p>
<h2>No. 3: Entitlement programs are hard in general to enact</h2>
<p>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 <a href="http://jhppl.dukejournals.org/content/20/2/329.abstract">studies of the U.S. health system,</a> the country doesn’t “have a comprehensive national health insurance system because American political institutions are structurally biased against this kind of comprehensive reform.”</p>
<p>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.</p>
<h2>Bottom line: Universal coverage unlikely to happen</h2>
<p>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.</p>
<p>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. </p>
<p>As long as the reasons above remain, there is little reason to expect universal coverage in America anytime soon.</p>
<p><em>Editor’s note: this is an updated version of an article that originally ran on October 25, 2016.</em></p><img src="https://counter.theconversation.com/content/77591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Timothy Callaghan does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Arguments about the AHCA showed deep disagreement on health care coverage. Could this move us toward universal coverage, which some say could be simpler? Don’t hold your breath.Timothy Callaghan, Assistant Professor, Texas A&M University Health Science Center, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.