On Universal Healthcare

Healthcare is in the political news in a way I didn’t expect. Of course we’ve all watched the GOP rants against the Affordable Care Act, and Congress’s repeated votes to repeal it. They are like this guy, and just as successful:

I was prepared for more of these antics, and we will probably see them. But what caught my attention this week was the debate between Hillary Clinton and Bernie Sanders: what is the correct path from what we have today to the longstanding Democratic Party goal of true universal healthcare? Sanders is going all-in with a model he calls Medicare for all. Clinton is being more pragmatic and risk-averse and wants to “build on” the Affordable Care Act rather than “replace it” with a different program. Sanders cites gaps and inefficiencies of the current model; Clinton cites the divisiveness of the last healthcare debate and the risk of Republican attacks. Sanders and Clinton both make valid points.

I have decided which approach will get my support, and maybe I will write about that another time. But for now, can we just cut through some of the mythology that surrounds the terms used in this debate? Can we be clear about what the goal is?

In my view, healthcare means health services. It means affordable and local access to the medical professionals and facilities that my family and I need to live healthy, productive, and long lives. Health insurance is protection against financial ruin. It puts a cap on the costs that a family might pay for health services, whether that’s regular doctor visits or more extreme or costly treatments in the event of an accident or severe illness.

Fine, a health insurance policy might include some health services, like regular checkups for children, just like some auto insurance policies include free windshield repair or roadside assistance. But the existence of policies that deliver such benefits leaves us far short of truly ensuring that all Americans have access to affordable health services.

When progressives talk about universal healthcare, they need to ask themselves whether they really mean universal protection against financial ruin. If they do, they are much more likely to accept a step-wise, patch-work, and unfair model of coverage. As long as we reduce or eliminate medical bankruptcies, we’re good! Right? We just need to “cover” more and more people, no matter how we do it.

And fundamentally that’s the problem with the discussion of this issue: everyone has a different definition of what it means to be “covered” and has had a different experience with the way “coverage” and “services” are delivered. People with employer-provided insurance, and especially those with high-end plans that ask for only small personal contributions, have no idea what it’s like for a person buying his own coverage, or coverage for his family. People with high-end employer-provided plans have no idea what questions an insurance consumer needs to ask himself when he is shopping for a new policy:

  • Can we afford a premium of $785 for my family of 3? Sure, no problem.
  • That plan has an annual family deductible of $7,500. Seems like a big number.
  • We’re pretty young and healthy, will we really go to the doctor so much that we would have to spend that $7,500 before the insurance kicks in? No, doesn’t seem like it. (Then what are we getting for our $785/month?)
  • But if something terrible happened, like a car accident or a severe illness, could we come up with $7,500 (every single year until we’re healed)? Or could we afford that number if we have a baby? Yes, I guess so. [Contemplates draining savings accounts and dipping into retirement funds.]

These questions are like the life-and-death versions of “is my car nice enough to carry collision insurance?” My guess is that most Americans have never had to go through this process, and if they did they would feel as uncomfortable and as exposed as my family did when we bought our own insurance policy for a short time in 2014. (And by the way, there is an equivalent fear framework for those Americans with employer-provided plans: what if I lose my job?)

Universal healthcare needs to be better than this. It needs to be easier, more affordable, and… more universal! When we envision a population-wide healthcare program, we should not have Americans asking themselves these questions, making decisions about health and quality of life based on affordability and the likelihood of an accident or illness or job loss. Universal means the same high standard for everyone. The question is how we get there, and when, and whether it’s possible to achieve that universal standard in a system of for-profit insurance and pharmaceutical companies.

Disclosure: I am originally Canadian and I grew up with universal healthcare. I moved to the United States in 1990 and I became a United States citizen in 2010. Despite now living in the United States for longer than I ever lived in Canada, framing the healthcare debate in terms of bankruptcy-prevention and for-profit insurance companies just feels… foreign.

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