America’s failure to provide universal health-care coverage to its citizens has been for decades a glaring symbol for progressives of the gap between our lively political democracy, still a beacon to the world, and our lack of economic and social democracy. In 2008, when Barack Obama was elected president, nearly 49 million Americans, 16 percent of the population, were without health insurance and lack reliable access to medical care. Health care was a central issue in that year’s presidential campaign. The passage in 2011 after a furious political battle of the historic Patient Protection and Affordable Care Act, popularly known as Obamacare, was the signature achievement of Obama’s first term of office.
Once Obamacare is fully operational, it is estimated that as many as 93 percent of Americans will have coverage. And America will still be the only industrialized nation without universal care.
Access to health care emerged as a major economic and political issue after World War I, with the widespread emergence of reliable and increasingly complex modern medicine. The first major American health insurance plan, Blue Cross, was developed in 1929 by Baylor University Hospital in Dallas. It quickly spread nationwide during the 1930s as a way for hospitals to fill beds during the Great Depression, and was taken over in the late 1930s by the American Hospital Association as a national, not-for-profit organization. It was marketed in bulk for purchase by companies as a benefit for their employees. By 1940, 9 percent of the American population was covered by Blue Cross or one of its growing number of private competitors.
In 1943, the Internal Revenue Service made employer-based health insurance tax-free, and in 1949 the National Labor Relations Board ruled that unions could negotiate for health coverage as part of a labor contract. By 1960, more than 60 percent of Americans were covered. Employer-based coverage peaked in 1987 at close to 75 percent of employees. It has been declining steadily since then. By 2010, just over 58 percent of Americans below age 65 had employer-based coverage. The reasons for the decline are a combination of factors: declining union influence; downward pressure on overall employee compensation as a share of company revenue; and the rising cost of insurance, which in turn is due to a combination of increasingly sophisticated medicine and changes in the economics of insurance coverage.
Universal, government-guaranteed health coverage emerged as a popular proposal after World War II. Harry Truman proposed it in 1945, but as unable to get it through Congress. The United Nations took up the cause of universal health coverage at its founding in 1945 as part of its human rights agenda, and it was included as one of the package of economic rights incorporated in the Universal Declaration of Human Rights adopted by the General Assembly in 1948 (along with the right to a job, trade union membership, leisure, and “food, clothing and housing”).
The United States, however, took exception to the economic clauses in the declaration. During the course of the 1950s and 1960s, most countries enacted some form of universal health care, but the U.S. Congress rejected efforts by the Truman, Nixon and Clinton administrations to follow suit.
In 1965, under President Lyndon B. Johnson, Congress adopted a limited form of universal coverage for persons over 65, Medicare, as well as the state-administered Medicaid, which covers low-income families under rules that each state defines separately. A third program, the Children’s Health Insurance Program (CHIP), adopted by Congress during the Clinton administration in 1997, covers children in families with incomes slightly higher than Medicaid permits. As a result of these three programs, the vast majority of the uninsured are between 18 and 65, including more than 28 percent of Americans aged 19 to 34 (as of 2010).
The decline in employer-based insurance includes both a steady decline in the number of firms that offer coverage plans and an increasing tendency of plans that are offered to be beyond the reach of individual employees. Firms that continue to offer coverage increasingly shift the burden of payment for premiums to the employee. Plans tend to include steadily increasing deductibles, making them less appealing to employees. And insurance companies have shifted from social insurance to actuarial coverage in which more costly patients are charged higher premiums or simply dropped.
Progressives face a complex challenge in fighting for health care for all. The passage of Obamacare was an historic achievement, but it is highly imperfect.
A study conducted by Harvard Medical School in 2009 concluded that lack of health insurance was responsible for nearly 45,000 deaths per year in America. If Obamacare performs as hoped, it will reduce the percentage of Americans without insurance by more than half, but it will still leave more than 25 million uninsured. That means tens of thousands still at risk of unnecessary death.
European and Canadian systems of universal health care, most of which rely on a single-payer system, cut the proportion of a nation’s GDP that is spent on health care by up to half, and yet yield better results than American health care by almost every measure.
For all that, conservatives remain bitterly opposed even to the modest reforms passed in 2010. As of 2013, numerous states with Republican governors and legislatures were refused to expand coverage of Medicaid, a key element in the Affordable Care Act, and Republicans in Congress were intent on overturning the act itself. Moderate Republicans who supported health care reform in earlier decades have been scarce in recent years.
And yet, Republican governors in some states were willing to implement the plan as envisioned. Progressives have long struggled with the dilemma of whether to support Democratic candidates because of the rightward drift of the Republican party or to support moderate Republicans in order to move the center of gravity of American politics back toward the arc of social justice. Nowhere will that dilemma be felt more sharply in the decade ahead than in the struggle for universal health care access.