Though most developed countries in the world regard universal health care as a “right,” it is undoubtedly correct to say that the U.S. does not. But at least since Roosevelt’s 1941 “four freedoms” speech we have regarded health care as a significant aspect of the “freedom from want.”
Accordingly, the U.S., by a wide margin, spends more per capita on health care than any other nation in the world; we’ve led in per capita health care spending for decades.
Despite this high level of spending, a recent Commonwealth Fund study that compared health outcomes for 11 high-spending nations noted “… the U.S. fails to achieve better health outcomes than other countries …” Of the 11, it was last overall, and last or near last in quality of care, access, efficiency, equity and healthy lives.
Other data makes clear that 30 nations have a higher life expectancy than the U.S. Fifty nations achieve a lower infant mortality rate. Twenty-nine nations achieve a lower child (1-5 year) mortality rate. The U.S. is 45th in maternal mortality. These figures, too, have not significantly changed in decades.
The disjoint between our health care spending and health outcomes is shocking, and though several factors contribute to this anomaly, one stands out – too many people are without health insurance. In 2009, prior to the Affordable Care Act (ACA), nearly 51 million, 1 in 6 Americans, (mostly children, the poor, sick or elderly) were uninsured.
The single most important achievement of the ACA is that it reduced the number of uninsured by 22 million people; but today, 29 million people remain without health insurance. The ACA might have come closer to its goal of insuring 30 million people were it not for implacable, ideologically driven Republican opposition.
A Republican-controlled Congress for six years blocked any/all useful corrective and/or fine-tuning amendments to the ACA, and 19 states (almost all Republican controlled) have resisted full participation in ACA benefits.
Now Republicans control Congress and the White House; under the mantra “repeal and replace,” House Speaker Ryan’s health insurance plan is on the table. In my view, it doubles down on the mistakes of the past. Here are six reasons to reject the plan.
1. Impartial observers agree the number of uninsured will rise. The only question (that Mr. Ryan can’t or won’t answer), is how fast, and by how many? Bottom line: Ryan/Republicans are not troubled by a rising number of uninsured people –history says they should be.
2. The Ryan plan cuts the level of federal subsidies that enabled millions of uninsured to be able to afford health insurance. More importantly, it would distribute subsidies not on the basis of income/need, but by a system of fixed (slightly rising) age-based tax credits. Result: wealthier people get subsidies they do not need at the expense of poorer people.
3. The Ryan plan eliminates corporate and individual mandates to provide and/or to purchase health insurance. A weak/unfair incentive to maintain health insurance once purchased is provided. Both mandates are essential to expand the insurance pool and thereby keep insurance costs down. Result: health insurance premiums will rise; ignoring mandates widely used in other settings is hypocritical.
4. In 2020 the Ryan plan ends Medicaid expansion as a way to fund/subsidize health insurance. Federal subsidies to purchase/renew health insurance post-2020 will be reduced; individual Medicaid payments will be capped; the state’s share of health insurance costs will either increase or eligibility requirements will be tightened. Result: the number of uninsured will rise slowly at first, but more rapidly after 2020.
5. The Ryan Plan allows insurance companies to raise the costs of health care insurance for the elderly more steeply than the ACA allows. Result: fewer elderly will be able to afford coverage.
6. The Ryan plan eliminates a range of taxes that offset (in part) ACA insurance subsidy costs. Result: health insurance premiums will rise.
In sum, the Ryan plan will increase the number of Americans without health insurance; health outcomes in the nation will not improve; the plan robs from children, the poor, sick and elderly (who are seen as undeserving) to benefit the wealthy. It “ought not to pass.”
Orlando Delogu of Portland is emeritus professor of law at the University of Maine School of Law and a longtime public policy consultant to federal, state, and local government agencies and officials. He can be reached at email@example.com.