The many roads to universal health care in the US

The evolution of the American health-care system and interesting roots. Starting in the 19th century, to prevent wage loss due to illness, European nations developed national insurances similar to the current American Social Security.

These systems evolved into national universal coverage. The United States, on the other hand, has a financially unsustainable and fractured system that fails to embrace health care as a human right as compared to other developed nations. American exceptionalism, the for-profit health-care industry, and physicians’ concerns over personal income are the three key elements that hinder progress toward universal health care.

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During the 1930s American physicians and hospitals established prepaid, multi-specialty groups that charged fees for services. Other groups such as labor unions adopted similar models, with preset physician salaries, per-patient fees, and free preventive services.

As these entities grew, the American Medical Association (AMA) opposed the model. They feared the loss of physician autonomy and earning potential. They lobbied for legislation to dismantle multi-disciplinary groups and advocated the “fee-for-service” model.

During WWII wage controls prevented employers from increasing workers’ salaries, but permitted such incentives as tax-deductible health-care benefits, leading to the employer-based insurance model today.

Presidents Truman and Roosevelt proposed federally funded universal coverage, which the AMA again opposed, successfully playing on the pervasive fear of communism, and labeling it “socialized medicine” and a “communist plot." Despite the lack of universal coverage, from 1940 to 1965 the proportion of insured Americans rose from 25 percent to 80 percent, drastically increasing spending. Doctors ceded control over their practices to insurers, and had to navigate regulatory and billing complexities.

As the insurance company model expanded, elderly and impoverished Americans were left without coverage. In 1965 President Johnson took steps toward universal care with Medicare and Medicaid. He aimed to provide coverage for the most vulnerable Americans: the poor, the elderly and the children. This also forced desegregation of hospitals. Despite this, progress toward comprehensive coverage was halted until the passage of the Affordable Care Act (ACA) in 2010.

Today, both the European Union and the United Nations recognize health care as a human right. The United States does not. Medicare, Medicaid and the ACA represent substantial progress, covering more vulnerable Americans (children up to age 26, pre-existing medical conditions, expansion of Medicaid). The ACA cut the number of uninsured by half. But costs are skyrocketing, premiums are rising, and more than 27 million Americans remain uninsured.

The U.S. spends 18 percent of gross domestic product on health care ($3.4 trillion in 2016), more than twice that of other advanced nations and still delivers a lower volume of care, with worse outcomes. In 2016, out-of-pocket spending on health care pushed more than 10.5 million Americans into poverty and insurance costs for employers have nearly tripled since 1999.

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Today, health care is the most important issue to voters, and 58 percent of Americans favor replacing the ACA with a federally funded universal health-care system.

Expanding Medicare coverage to more (age over 50 years; “Medicare for more”) or all Americans (“Medicare for all”) are popular but contentious concepts. “Medicare for All” has become a popular rallying cry, but it means different things to different people.

The many health-care plans and proposals (Medicare, Medicaid, ACA, and Medicare for more or for all) have one common purpose: to achieve universal health care in the United States. Models of successful, affordable and accessible universal health-care systems already exist in other countries.

They vary by country, ranging from mostly government-based single-payer systems (Sweden, Norway, Australia), to health-care systems offering government-sponsored options and different degrees of private insurances (Canada, United Kingdom, France), to private insurance plans under government supervision (Germany, Netherland).

The German and Dutch health-care models are the closest to the ACA, but with an enforced individual insurance mandate. They demonstrate how the ACA might have worked ideally were it not weakened by ideological and political currents, and with better government supervision to eliminate waste, fraud and excessive profits.

On the road toward universal health care in the United States, and accounting for the sensibilities and preferences of Americans over decades (American exceptionalism, freedom of choice, anti-socialism), offering a government-based single-payer public option that excludes private insurances (as proposed by some Democratic presidential candidates) is a “dead-on-arrival” proposition. It is also highly vulnerable to derogatory presidential campaign slogans (socialized medicine, medical communism) that could sway many Americans.

Also, 80 percent of the 181 million Americans who have employer-based private insurances are satisfied with their coverage. Any proposed health-care models must appeal to a majority of Americans.

Rather than sacrifice what is reasonable for an unachievable ideal, health-care proposals must keep the current private system, but offer the government-sponsored Medicare and Medicaid to more Americans. Any reform must also start by removing restrictions on government programs’ ability to negotiate bulk drug prices and establishing a national formulary. The majority of Americans favor this.

Several bills have been introduced to make Medicare a public option, available to individuals and employers. This could be introduced initially to people ages 50-64 (Medicare for more) or to all Americans who want this form of government insurance (Medicare for all). Expanding Medicare eligibility to more or to all Americans represents both the most strategically viable and cost-effective solution to reduce spending and achieve universal coverage.

Allowing broader government-sponsored programs to run in parallel with private insurances represents the spirit of American ideals (capitalism, free market forces, freedom of choice) and will, through incremental remedial steps, gradually and ultimately reveal the best health-care system applicable to the United States.

Hagop Kantarjia, M.D. is the chairman of the Leukemia Department at The University of Texas MD Anderson Cancer Center and a non-resident fellow in health policy at Rice University’s Baker Institute. Greg Jones, B.S., is a medical student at McGovern Medical School, UT Health contributed to this article.