Why Doesn’t the U.S. Have Universal Health Insurance?

By: Samantha Powers

Edited by: Madison Bruno and Sarah Wachs

For decades, the United States health insurance system has been a talking point among political candidates. Former President Barack Obama ran in 2008 with the promise of improving health insurance coverage for all Americans, culminating in the passage of the Affordable Care Act in 2010. Six years later, former President Donald Trump ran on a promise to “repeal and replace” so-called “Obama-care” with a new system, which he only partially fulfilled. As the politics surrounding health insurance in America continue to fluctuate, the uninsured population is suffering. According to the CDC, 27.6 million Americans were uninsured in 2022 — a figure reflective of higher insurance rates since the onset of the COVID-19 pandemic. [1] Health insurance has proven to lead to better treatment and health outcomes, meaning those lacking financial resources are at the highest risk. Low socioeconomic communities are subject to increased risk of conditions such as obesity and type II diabetes, according to the National Institute of Health.[2] These poor health outcomes are unacceptable for a nation as advanced as the U.S.. Universal health insurance would improve health outcomes for millions of Americans, but like all systems, it has its shortcomings. To understand this further, we must look at historical efforts to establish universal health insurance in the U.S.

The U.S. has historically used a mixed public and private approach to health insurance. In contrast, other post-industrial Western nations use almost entirely public systems, generating better health outcomes overall.[3] Despite evidence that a public system would improve health outcomes, U.S. politicians have historically struggled to gain traction in their efforts to establish universal healthcare. In 1994, former President Clinton attempted to pass the Health Security Act, which would have required individuals to purchase baseline health insurance and would have required employees to provide it.[4] The bill — which did not pass — bore a lot of similarities to Obamacare, but with a key difference: it put more pressure on users of employer-based insurance to make an immediate switch to the federal insurance marketplace. Clinton struggled to garner public support for the bill, and his efforts ultimately failed.

Former President Obama picked up the torch and crossed the finish line with his passage of the Affordable Care Act of 2010. The ACA, also known as the Patient Protection and Affordable Care Act, was passed to provide impoverished consumers with premium subsidies, expand Medicaid, and support lower-cost healthcare delivery methods.[5] Following implementation, the act saw great success. According to the New England Journal of Medicine, estimates of the number of people who have gained health coverage since 2010 range from 7 million to 16.4 million. In addition, young adults, people of color, and those with low incomes — groups that have “historically been at the greatest risk for lacking insurance… have made the greatest coverage gains.”[6] Not only did the ACA improve health insurance coverage nationwide, it also made strides to protect some of the most vulnerable populations. 

Still, this golden age for U.S. health insurance could not last forever: in the years following the ACA’s passage, it has faced legal challenges across the branches of government. The Supreme Court has upheld some aspects of the ACA and struck down others. In NFIB v. Sebelius, the Court famously upheld the ACA’s mandate that individuals must purchase health insurance or else they must pay a fine, deciding to treat the policy as a tax.[7] In King v. Burwell, the Court weakened the ACA when it decided that federal subsidies should flow to all states, regardless of whether they have established their public insurance exchanges.[8] The Trump administration also weakened the ACA through a series of executive orders intended to “repeal and replace” the law, but the former president’s efforts fell short of his campaign promises — Trump only repealed parts of the ACA, and he offered no replacement model for the healthcare system. Now, the ACA continues to benefit millions of Americans, but not to the extent it once did. After almost a century of progress in expanding access to health insurance, the United States has regressed due to political pushback and partisan infighting. Americans deserve better than this legal instability: access to affordable health insurance should not depend on who is in office.

When using a comparative approach to the health insurance systems in other developed nations, it is clear that the United States could be doing much more. For example, Nordic countries employ a “welfare state” model that allows for comprehensive, institutionalized, and universal health insurance for their citizens, “regardless of social status or geographic location.”[9] The systems are grounded in public consent and political participation, two major democratic values held by the U.S. — so why does our system not function the same way? One possible explanation is that Nordic nations are far less populous and diverse than the U.S., meaning that a one-size-fits-all approach is more difficult to cater to the U.S. population. Another explanation is that universal healthcare is costly, creates inefficiency in the medical system, and works against progress and innovation in the medical field.[10] This is partially true: in nations with universal healthcare, wait times for medical procedures are much longer. While there is no perfect system, a universal healthcare model ensures that the most underprivileged do not get left behind. Furthermore, universal healthcare can actually save money: uninsured individuals with chronic diseases like diabetes and heart disease cost the U.S. more than their insured counterparts.[11] Over time, a healthier populace will pay dividends to the well-being of the U.S. at large and reduce socioeconomic inequality. While a universal healthcare system requires lawmakers to sacrifice some things, it is worth it to protect American lives.

Notes:

1. “U.S. Uninsured Rate Dropped 18% during Pandemic,” Centers for Disease Control and Prevention, May 16, 2023, https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2023/202305.htm.

2. Gabriel Zieff et al., “Universal Healthcare in the United States of America: A Healthy Debate,” Medicina 56, no. 11 (2020): 580, https://doi.org/10.3390/medicina56110580.

3. Gabriel Zieff et al., “Universal Healthcare in the United States of America: A Healthy Debate,” Medicina 56, no. 11 (2020): 580, https://doi.org/10.3390/medicina56110580.

4. Health Security Act, H.R. 3600, 103rd Cong. (1994).

5. Patient Protection and Affordable Care Act, Public Law 111-148, 124 Stat. 119 (2010).

6. David Blumenthal, Melinda Abrams, and Rachel Nuzum, “The Affordable Care Act at 5 Years,” New England Journal of Medicine 372, no. 25 (2015): 2451–58, https://doi.org/10.1056/nejmhpr1503614.

7. National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012).

8. King v. Burwell, 576 U.S. 473 (2015).

9. Jon Magnussen, Nordic Health Care Systems: Recent Reforms and Current Policy Challenges (Maidenhead, UK: Open Univ. Pr., 2010).

10. Gabriel Zieff et al., “Universal Healthcare in the United States of America: A Healthy Debate,” Medicina 56, no. 11 (2020): 580, https://doi.org/10.3390/medicina56110580.

11. Gabriel Zieff et al., “Universal Healthcare in the United States of America: A Healthy Debate,” Medicina 56, no. 11 (2020): 580, https://doi.org/10.3390/medicina56110580.

Bibliography:

Blumenthal, David, Melinda Abrams, and Rachel Nuzum. “The Affordable Care Act at 5 Years.” New England Journal of Medicine 372, no. 25 (2015): 2451–58. https://doi.org/10.1056/nejmhpr1503614. 

Magnussen, Jon. Nordic health care systems: Recent reforms and current policy challenges. Maidenhead, UK: Open Univ. Pr., 2010.

“U.S. Uninsured Rate Dropped 18% during Pandemic.” Centers for Disease Control and Prevention, May 16, 2023. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2023/202305.htm. 

Zieff, Gabriel, Zachary Y. Kerr, Justin B. Moore, and Lee Stoner. “Universal Healthcare in the United States of America: A Healthy Debate.” Medicina 56, no. 11 (2020): 580. https://doi.org/10.3390/medicina56110580.