Making the case for universal coverage

I was doing a bit of prep this week for my Fall 2012 class, Intro to the U.S. Health Care System.  I have taught it many times, and I am trying to decide how to put what has happened the past three years into perspective for 19 year olds (with a big shoe left to drop next week).

A reporter from another country interviewed me this week and asked “why doesn’t the U.S. have a universal system of health insurance coverage?” From 1999-2008, I gave roughly the following answer:

  • Because organized medicine has always opposed reform efforts
  • Advocates have failed to make the case to the “middle class” that reform was in their best interest (and efforts to do so were always portrayed as giveaways to the poor)

Of course many professional and industry groups who had historically opposed reform supported the ACA, so that was very different this time. And the arguments for why coverage expansions were important also changed. I perceive that advocates for health reform made a much more forceful argument about the economic costs of the uninsured to those with insurance during the ACA debate. There were fewer appeals to (moving toward) covering everyone because it was the morally correct thing to do, and more energy was expended to make the “business case” that the insured were already paying through cost shifting, so we might as well do so in a more straightforward fashion.

Paradoxically, as advocates honed the ability to make this case rhetorically, there was emerging evidence that cost shifting may not be as large as once thought, and that spillover effects may actually work in the opposite direction if there are coverage expansions to low income persons (actually the theoretical notion was from a 1994 book by Michael Morrissey, but more empirical work was coming about). This doesn’t mean there is not a cost shifting effect: in fact regardless of any actual economic impact of cost shifting, there is most certainly a political or negotiating effect (if I run a hospital, my answer to why I can’t take a lower price from a private insurance company will be cost shifting, regardless of what the magnitude actually may be; and hospital systems are gaining market power).

However, this type of discussion–what amount of money is shifted to the premium of the insured, and even the opposite argument of spillover effects via coverage expansions of low income persons that may benefit the privately insured, actually obscures the human face of persons not having coverage as the reason to move toward universal coverage.

It seems that in some past reform efforts advocates may have only focused on the morality of moving toward universal coverage. In the latest round, more nuanced economic arguments were more successfully advanced, but the main reason to develop a universal insurance system may have been lost in the shuffle.

(cross posted at freeforall)

Author: Don Taylor

Don Taylor is an Associate Professor of Public Policy at Duke University, where his teaching and research focuses on health policy, with a focus on Medicare generally, and on hospice and palliative care, specifically. He increasingly works at the intersection of health policy and the federal budget. Past research topics have included health workforce and the economics of smoking. He began blogging in June 2009 and wrote columns on health reform for the Raleigh, (N.C.) News and Observer. He blogged at The Incidental Economist from March 2011 to March 2012. He is the author of a book, Balancing the Budget is a Progressive Priority that will be published by Springer in May 2012.

28 thoughts on “Making the case for universal coverage”

  1. Okay, Don. To what extent does the public health argument play? It’s in our own best interest to have universal coverage. Large, anonymous concentrations of people (cities) act as disease amplifiers — factors that discourage people from seeking treatment early turn the gain up on the amplifier.

    1. There are many reasons to have universal cover. Public health as you say, both direct impact of infectious diseas (TB, etc.), and health of the population/workforce, financial (cost shifting whatever the magnitude), moral/ethical. further, I think that without universal coverage we will never be able to truly address costs, because the reflexive answer to any providers being asked to do more is “I can’t because I have to care for the uninsured.” If you can crack the coverage question, then more focus on quality/appropriateness, etc. All the arguments are legit and need to be made, but a moral/ethical one that focuses on benefits to the newly covered, and protection for you and your family if you become uncovered, have to be a part of it….it will cost more to insure more.

  2. I think it’s racism. Americans will give up all kinds of benefits to keep immigrants and minorities from getting them. Sad, but true.

    1. Racism is part of it. Scots-Irish individualism is also part of it. Only in America can a plea for social solidarity be viewed as morally inappropriate, as opposed (say) to misguided. The anti-union animus so strong in many parts of this country is not based on racism. I’m sure that there are other explanations that go beyond interest group politics, as well.

      1. I grew up in the South and had a great uncle who was chased out of town after town he lived in for trying to organize cotton mills. Everyone called him a communist, but he came from a long line of small business owners and had worked in the mills himself at his father’s insistence to make sure that he understand what hard really entailed.

        He was horrified by what he saw and wanted to do something about it. I believe that the reason why people in that part of the country who oppose unions so vehemently, but who would benefit so much rom them do so is a combination of fear and east persuasion. Fear of losing jobs and the easy acceptance of labels such as communist.

      2. “Only in America can a plea for social solidarity be viewed as morally inappropriate, as opposed (say) to misguided.”

        A lot of Americans don’t see pleas for increased government as pleas for “social solidarity”. To a lot of Americans, “social solidarity” conjures up images of, say, Catholic hospitals. Fraternal organizations. Private charities. And what do they see? The government trying break those to the yoke, saying, “You can only do good on our terms, or not at all.”

        Government, arguably, is the enemy of social solidarity, not an instance of it. Solidarity, after all, stripped of choice, is just a chain gang. And the government doesn’t really do choice, that’s not it’s thing.

        1. Sorry, not buying. I’ll stick with the preamble to the Constitution if its ok with you. We the people. I think it’s a decent summation of the empirically discovered reasons, through a lot of history and a much difficulty — what used to be known as “conservative” reasons — why we need to act together in an organized fashion through government. Insure domestic tranquility. Provide for the common defense. Promote the general welfare. Secure the blessings of liberty for ourselves and our posterity. Things like that.

        2. Once again, Brett, you’re slave to your ideology. You dream of a government-free America first, and then you pretend that the private sector would somehow step in to perform all kinds of good acts that government currently performs. No. You pretend that the government is only ever evil, which is false and a myth created by your Libertarian icons.

          If one believes, as I and many others in these forums do, that people have an inherent right to dignity, which includes not being allowed to die a painful death or starve, then the only answer is that occasionally a government created by the people must step in and help. Your mythical private charities simply don’t do enough, and never will. In your Libertarian, government-free dystopia, the poor and old would routinely die in degraded circumstances. Period. We tried this already, back in the mid-19th century and it was an abject, inhumane failure.

          1. In the liberal fantasy world, nothing happens if government doesn’t do it, and nothing really happens, if the federal government doesn’t do it. Somehow a democratic government elected by heartless fiends does good.

            And “social” means “government”, nothing else counts.

          2. No Brett. It’s not that private charity does nothing. It’s that it doesn’t do nearly enough.

            You can claim otherwise if you want, but history, as Matt says, is against you.

          3. Brett, you’ve created a bastardized, fictional strawman viewpoint that you’ve scrawled “liberal” on so that you can continually beat on it.

            I’m liberal and I believe in the private sector and market solutions to most problems. Government is far from the only or even the best solution to most cases. But I also believe that there are certain things that a free market doesn’t do well, and in those cases a mutually agreed-upon democratic government can work. My position is nuanced and rational and nothing like the idiotically simplified position that you constantly make up in these forums. “Social” does not only mean government–it means community, industry and government working together. This is why we form democratic governments in the first place, to assist with those problems that the private sector can’t fix.

            Yet you’re perpetually blinded by your own black-and-white, reductive ideology. In order for your ideology to work and be justified, you’re forced to misinterpret the views of others (by erecting straw men, golems, and puppets.) If you didn’t have these straw men, your ideology would fall apart.

          4. = = =
            Byomtov says:
            June 24, 2012 at 10:39 am

            No Brett. It’s not that private charity does nothing. It’s that it doesn’t do nearly enough.

            You can claim otherwise if you want, but history, as Matt says, is against you.
            = = =

            I’m going to have to disagree with you a little there. I suppose charity can be a good thing, but… I happen to have been fortunate enough to have been given the opportunities to develop certain aspects of myself (thank you public schools) and have been able to take up fairly well remunerated occupations through the course of my life.

            But why should the guy who wasn’t blessed with those opportunities, and who spent his life collecting scrap metal[1] and just getting by, be forced to depend on charity for his health care? Is he not a citizen the same as me? Does he not provide a useful service to our economy taken as a whole? Why should some citizens luck into the illusion of “self-sufficiency” and others be forced to beg for a tooth extraction from a religious organization? I find that concept deeply un-American.


            [1] Legitimately; not stealing gutters from houses.

        3. Brett Bellmore to English Dictionary:

          “A lot of Americans” == Brett and few other Randians who would do us a favor if they “went Galt.”

          “Social solidarity” == What Lenin and Stalin tried to impose in the former Soviet Union.

          By the way, Brett, it’s is an informal English contraction meaning it is. Its, on the other hand is a possessive adjective. They aren’t interchangeable. Just another quirk in English orthography. Also, since we are on apparently on a French binge (with laissez faire) let us recall Anatole France’s trenchant observation of the results of that sort of policy:

          The law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread.

          1. “Brett Bellmore is arguably wrong on every single issue.”

            The above statement is tautologically true. It cannot be proven false.

  3. Is there anyone at all who believes that the present American health care system is better than the numerous and varied developed-world systems with universal coverage, and does so on a basis deserving of the word “theory” in a plausible academic sense? It would seem to me that something that on massive evidence consistently produces equal or better results at much lower cost doesn’t have to do much begging for further theoretical justification.

    1. One rule of American exceptionalism is that we are not allowed to learn anything from other countries (except for reactionary economic policies). We are automatically the best at anything we do. We are like British sailors in the Northwest passage, locked in by ice, losing teeth to scurvy and toes to frostbite while insisting the healthy native people walking by have absolutely nothing to teach us.

      1. Do you have any evidence for the icebound sailors? It’s a nice story, and I buy the moral, but it has a whiff of urban legend to it. On the other hand, Jared Diamond documents in Collapse the slow death of the mediaeval Scandinavian settlements in Greenland, who persisted in trying to live from grass-fed cattle as the climate got colder, instead of learning to hunt seals from the Inuit. Towards the end they blamed it all on witches.

        1. I let Google do the search for me with the words icebound sailors northwest passage. Google found this for me:

          Northwest Passage
          With the end of the Napoleonic Wars in 1815, England, in an attempt to secure its naval superiority and the enormous commercial advantage that came with it, began what eventually became a decades-long endeavor to discover the Northwest passage. The Passage eluded explorers through Mary Shelley’s lifetime; as late as 1845, Sir John Franklin set out on an expedition that ended in the loss of the entire expedition of 129 men. The Passage was discovered only in the 1850s by Sir Robert McClure, who led one of the forty search parties that sought information on Franklin’s expedition. McClure’s expedition was icebound for nearly two years, and was rescued by Captain Henry Kellett; Kellett’s ship was in turn icebound for another year.

          In that paragraph, the name John Franklin was linked to this:

          Sir John Franklin, 1786-1847, English explorer.
          Franklin entered the navy at the age of fourteen and was present at the battle of Trafalgar (1805). In various expeditions in the 1820s he explored the Canadian arctic coast. Franklin set out in 1845 for the Northwest Passage with two ships, the Erebus and the Terror. In 1846, however, the ships became icebound in Victoria Strait. Franklin died the next year; the ship’s survivors tried to reach civilization on foot, but all 105 died of starvation and scurvy.

          Not an urban legend.

    2. ….equal or better results at much lower cost…

      There are massively higher costs in those other systems… because the price of Freedomâ„¢ lost is incalculable.

      Take Switzerland.

      As it is now, it’d break your heart — the shabby clothes, the queues in the stores for such meager goods, the whispered conversations about friends and neighbors who have disappeared in the night, Tor-proxy protected furtive visits to the American consular agency in Geneva’s website with asylum questions…

      All this because of their government’s individual mandate to purchase health insurance from a private carrier through an exchange. You’d think, 20 years after the fall of the Berlin Wall and the collapse of the Soviet Union, we’d seen the last of this kind of oppression, at least in Europe.

      Some day a Walesa of the Rhodanie will arise and lead those poor bastards in Lausanne to freedom.

      (Freedomâ„¢ is a registered trademark of the Republican National Committee. All rights reserved. Used with permission.)

  4. “We are like British sailors in the Northwest passage, locked in by ice, losing teeth to scurvy and toes to frostbite while insisting the healthy native people walking by have absolutely nothing to teach us.” Urban legend? Google search certainly turns up icebound British sailors succumbing to scurvy and frostbite; the cited passages, however, say nothing of healthy native people walking by!

    1. Need to read more passages, then, because this is in Wikipedia, which gives extensive citations at the bottom of its very long article. The quote is from the British newspaper The Guardian, quoting Canadian marine archaelogist Robert Grenier, who had studied the ill-fated expedition extensively:

      “After studying 19th-century Inuit oral testimony – which included eyewitness descriptions of starving, exhausted men staggering through the snow without condescending to ask local people how they survived in such a wilderness – …etc.”

  5. Is another factor the historic linkage of health insurance with employers? Because individual health insurance is so expensive, this gives employers a little more leverage with employees. How many people are working in crappy conditions, for crappy pay, who would quit (or demand higher pay) if they weren’t worried about health insurance?
    I suspect it’s not purely out of moral issues that Republicans have opposed any kind of universal non-employer provided coverage.

    1. It is SO moral issues – why else do the object so strongly to insurance that covers birth control and abortions?
      They believe your employer has the authority to to pick insurance that does not cover certain ‘naughty’ conditions, but a govt regulation (qua regular, or standard) requiring that coverage is tyranny.

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