Health care for all Americans so close — and yet so far
The United States is on the verge of a major achievement, one that almost no one seems to have noticed.
If — and right now this remains a big “if ” — some version of President Joe Biden’s Build Back Better plan gets back on track, we might finally join the ranks of every other rich nation on Earth and treat access to health care as a fundamental right.
All other developed economies already guarantee universal health coverage, at least to their own citizens. Wealthy, middle income, poor: Everyone is promised access to care, with each country using a slightly different regulatory, funding and delivery structure to meet that objective.
The United States, despite its exceptional wealth, has remained an outlier. It’s embarrassing.
The Affordable Care Act, passed in 2010, was supposed to bring us in line with our peers by covering populations that had long gone without access to insurance. Its patchwork of policy changes expanded Medicaid; created subsidized individual-market insurance plans; guaranteed minimum essential health benefits; and banned discrimination against people with preexisting conditions, among other measures. Was this all a bit kludgy? Sure. But the law did massively expand access to health care.
The number of nonelderly people without insurance declined from 48.2 million people in 2010 to 30 million in 2020. Ultimately — and infamously — the ACA still failed to achieve its goal of universal, affordable coverage. That’s due partly to design flaws and partly to deliberate sabotage by Republican politicians.
The bill’s authors, for example, had not expected that states might choose not to expand Medicaid. But the Supreme Court ruled they could opt out, and a dozen red states continue to do so even today. That alone has left about 2.2 million poor Americans, a majority of them people of color, without access to subsidized coverage.
Enter the Build Back Better bill, which has the potential to finally complete the unfinished business of Obamacare.
Outside of health policy circles, most of the public discourse about this enormous piece of legislation has focused on higher-profile, and perhaps more controversial, components. Quite a bit has been written about its climate and clean energy measures, for example. And the expanded child tax credit, universal pre-k and child care subsidies. And the jockeying over state and local tax deductions.
Buried among all these other programs are major transformations to the health-care system. If Democrats hadn’t crammed Biden’s entire economic agenda into this one bill (primarily for byzantine procedural reasons), the health care provisions would almost certainly be the star of months of news coverage — just as they were more than a decade ago, when health care constituted the entirety of the then-president’s centerpiece safety-net legislation.
Among the bill’s more important changes is one that would finally close the Medicaid coverage gap in those 12 nonexpansion states. Low-income residents of these states would become newly eligible for individual marketplace plans with no premiums and minimal outof-pocket costs.
The bill would expand individual marketplace subsidies, make more people eligible to receive them, and either reduce or eliminate premiums for huge swaths of the population. It would redefine what counts as an “affordable” health plan, for example, to set a lower limit on how much people are expected to pay for their coverage.
To the extent that Americans have any clue that Build Back Better intersects with the healthcare system, they’ve probably heard about the bill’s provisions to add Medicare hearing coverage or to reduce certain prescription drug prices. These are, no doubt, significant policy changes. But they’re arguably less significant than finally getting us to virtually universal eligibility for subsidized health coverage.
I say “virtually” universal because, unfortunately, some people would remain uninsured.
Undocumented immigrants have been deliberately left out of coverage expansions, for example. Additionally, absent an enforceable individual mandate, some Americans will opt out of coverage they qualify for. That might be because they think they don’t need insurance, they don’t realize they’re eligible for subsidies or they’ve decided that the federal government’s new definition of “affordable” still seems too expensive.
Because the U.S. health system remains a convoluted, glitchy patchwork of programs, people might roll off eligibility for one program without being automatically enrolled in new coverage, creating many opportunities for Americans to fall through the cracks. Perhaps worse, most of the big Build Back Better coverage patches I mention here are temporary.
So, this bill still wouldn’t represent the same permanent, moral commitment to health care as a human right that other countries have already delivered. But even if our achievement is temporary, it’s still worth highlighting and celebrating.
Assuming Democrats can get their act together and pass the darn bill, that is.