The Next Steps Toward Universal Health Care in America

Much was discussed about health care in this past election, but with narrow Congressional majorities coming in 2021, it remains to be seen what will actually change federally.  The Affordable Care Act ("ACA") was meant to be a first important step in health care reform -- a step to be built upon over time until we achieve universal access to health care.  

If the whole topic of health insurance and health care is a mystery to you, I highly recommend watching  Knowing Better's excellent and entertaining video explaining America's health care system, Healthcare | The Complete Moderate's Guide.  He will clearly explain premiums, deductibles, co-pays, Medicare, Medicaid, and the V.A. System.

I am going to assume from this point forward that you know what a premium is, what a deductible is, and what a co-pay is.  If you don't, then please watch the above video.

New York Times columnist and Nobel Prize Winner Paul Krugman has written about universal health care as requiring three basic components:

1. Everybody In (either through taxation or a mandate to buy comprehensive health insurance);
2. Nobody left out (no one can be denied health care or coverage due to pre-existing medical conditions or medical history);
3. Government Subsidies (to help make health care accessible to all.)

The United States could learn a lot from what is already working around the world.  Universal health care is provided and financed by a variety of methods around the globe, some of which Healthcare Triage has done brief video descriptions:

• In Switzerland, people are required to buy private health insurance on tightly regulated markets -- much more regulated than the ACA is currently. People buy voluntary supplementary insurance to cover co-pays.
   
• The world's top rated system is in France,  Everyone must pay for mandatory health insurance.  Voluntary health insurance provides supplemental policies.  Providers are both public and private. Co-pays are lower in France and quality is high.
  
  
• It wouldn't take much for the ACA to evolve into a system similar to Germany's.  Health insurance is mandatory, tightly-regulated, and non-profit.  Long-term care insurance is mandatory too.  Hospitals are both public and private.
  
  
• Australia's public "Medicare" system operates alongside a private system. About half the people have private insurance.
  
  
• Singapore has an interesting model.  Great outcomes with low percentage of GDP spent on healthcare.  Singapore has a mixture of public and private health care spending and public and private health care delivery systems.  There are also five tiers of service you can pay for.  What makes it unique is its reliance on mandatory Health Savings Accounts.  Workers are required to put aside 20% of their income into savings for various usages, including for health care expenses such as insurance. There is also an additional inexpensive catastrophic illness program that 90% of the population participates in.
  
  
• In Canada they have "single-payer health care" which they call "Medicare", which is similar to our Medicare program for senior citizens.  Interestingly, single-payer started in one Canadian province and spread nationwide province by province.  If the Federal government gave statutory permission for states to use Federal Medicaid money to help create single-payer systems in their states the same thing could happen here.
  
  
• In the United Kingdom, taxpayers pay for a publicly-owned and operated health care system that directly provides service through the National Heath Service.  The closest equivalent to this in America is our Veterans Affairs system.
  
  
• Taiwan has proven that you make a major leap from a system of private insurance to a single-payer model in one swoop. 

President-Elect Biden ran on a platform with a credible health care plan that included adding a robust public health insurance option open to everyone, as well as overcoming red-state, holdout resistance to the ACA's Medicaid expansion, and strengthening Medicare.

Unfortunately for my fellow progressives, a direct Taiwan-esqe leap from what we have now to Medicare-for-All is likely not on the cards.  It couldn't pass the Senate.  Even getting any kind of federal public option or Medicare-Buy-In through a narrowly divided Senate with a legislative filibuster will be extremely tough.

As a backup plan, I would encourage Congress to pass a law that gives states statutory ability to use their Medicaid funding to establish public options open to all and/or single-payer systems within their states.  A few blue states could start a nationwide trend similar to what happened in Canada in how their "Medicare-for-all" system started in one province and went national.

One of the ways I would improve the existing ACA is to add adult dental, vision, and hearing benefits to the available plans for purchase on the exchanges.  Currently, those benefits are available those benefits are available to children on ACA "Bronze", "Silver", "Gold", and "Platinum" plans.  Let's add "Diamond- level plans which also include adult dental, vision, and hearing benefits too.  Yes, people could go purchase those benefits separately if they want them, but we want to make peoples' lives simpler and easier, not more complicated.  One-stop shopping would be helpful and worth it to many people.

There are also public option proposals currently floating in Congress, including ones that would call for a Medicare-administered public health insurance option.  One would hope that Democrats would use the Senate filibuster-bypassing, budget-reconciliation process to make it happen.

Social Security and Medicare were first established as limited programs and then gradually built upon over time into the universal programs as we know them today.  Let's keep moving forward in health care until we have universal access to insurance and care.  Let's not get stuck though on assuming that only one specific model of universal health care is acceptable.  The world offers us lots of examples of he we could move forward, and all of them are an improvement.  If we remain flexible in approach, we will get there sooner rather than later.  The ACA offers federal and state flexibility to compromise and do just that if we will allow it.

The "Public Option" in Health Care is Alive and Well in California

Every once in while I like to comment on non-transit issues on this blog.  In this case, I'd like to take on health care in California.

One of the components of the Affordable Health Care Act (a.k.a. "Obamacare") that people are missing is how much latitude each state has in implementing it. During the development of this legislation advocates for a national single-payer system (a.k.a. "Medicare-for-All") were not even allowed to come to the table to make their case.  Even the compromise position, giving everyone access to a public health insurance option, tragically couldn't get past a Senate filibuster.

However, thanks to this legislation, individual states can follow Vermont's example and pursue single-payer health care or at least place public health insurance plans on their state's coming health insurance exchanges as a state "public option".

Now I still from a policy standpoint prefer Medicare-for-All or single-payer health care.  Twice single-payer health care has passed the California state legislature only to be vetoed by Governor Schwarzenegger.  Now that there is a Democratic Governor who would be expected to be favorable to the legislation, SB810 is unfortunately stalled in the legislature thanks to insurance industry lobbying.

Several California counties have public health plans already, and California is likely to even have a choice of public health insurance plans as progressive counties like San Francisco and Alameada are looking to putting their public plans on the statewide exchange.

Read this Article: The Public Option is Alive and Well in California


The good news for health insurance reform activists, is that it looks as if in California we will at least have one or more public options on our state's coming health insurance exchange.  Even if "Obamacare" is struck down by the Supreme Court, the California state legislation creating a state health insurance exchange still stands.

The question now becomes, are county plans on the statewide exchange accountable to county Boards of Supervisors the best way to give access to public health insurance options?  Should a statewide public plan accountable to the Governor and the Legislature be include on the state exchange?  Could Medical be turned into a statewide public option open to everyone?

Watch this space for news about this issue unfolds over the next two years.