Why is universal health care unpopular in the United States?
The recent debate concerning the ambiguous future of Obamacare has completely dominated the American political agenda sparking more interest in the concept and attitudes towards universal health care in the United States, which is financed by for-profit and constitutes of loosely regulated private insurance companies. The United States is the only modernized Western nation worldwide that does not offer publicly funded health care to all its citizens. This essay aims to analyze the factors which influence the unpopularity involving the implementation of universal health care in the United States. The factors selected for discussion include the capitalist culture of the United States, heavy opposition from insurance companies lobbies, and a lack of a successful model due to the drawbacks of the current health care systems in Europe. In order to understand the heavy controversy surrounding American health care, this essay will firstly analyze and compare the past and contemporary health care coverage in the United States to depict the continuous efforts from the opposition to undermine any progress in this field throughout time. Secondly, this essay will identify the contributing factors that ultimately restrict any progress, reform, or even enhance the difficulty of implementing universal health care. Finally, through analyzing these factors, I will argue how the power of the opposition has been the most influencing factor in negatively politicizing universal health care in the United States to ensure its blockage.
The question assumes that universal health care in the United States is unpopular. It is correct to assume its unpopularity, as the country remains the only developed Western democracy to implement national health care. The campaign for any sort of national health insurance has dated back for almost a century in the United States. Numerous times advocates experienced success in reforming health care, however, the opposition has always defeated them. The dynamics influencing the lack of success regarding the evolution of these reforming efforts reveal distinct elements of American character in health care. Initially, the federal government played a limited role in the development and implementation of health care policy, shifting the responsibility to the states (Lee and Benjamin: 1994:131). During the Progressive Era, in the early twentieth century, President Roosevelt was the first President to campaign for health care overhaul through his 1912 “Bull Moose” presidential campaign. However, Roosevelt’s campaign was heavily opposed and successors were mostly conservative politicians, who delayed the issue of social welfare on the national agenda. In 1935, The Social Security Act was implemented by President FDR, establishing the Social Security Program, providing benefits for the elderly and financial assistance to the states for public assistance programs to children and elderly in need. The American Medical Association (AMA), opposed the inclusion of national health coverage as part of the Social Security Act, and thus FDR failed to incorporate this clause within the law for fear he would fail in Congress. The Social Security Act would eventually provide the philosophical and statutory basis out of which would emerge Medicare and Medicaid (Lee and Benjamin: 1994:135). In 1965, President Johnson enacted both Medicare, a program that provides health coverage to the elderly and disabled, and Medicaid, providing health coverage to low-income individuals. Nonetheless, the for-profit medical industry strongly opposed the establishment of these policies. The Medicare and Medicaid system have contributed to the contemporary health care financing problems facing the United States. The Medicare and Medicaid compromise provided a public subsidy to the health care industry and protected that industry from more universal health care plans (Steinmo and Watts: 1995:350). During Truman’s tenure, AMA opposed his proposals for national insurance in 1945 and again in 1948-1949. In 1993, President Clinton developed the “competition within a budget” plan, known as the Health Security Act, in response to heavy public opinion for health care reform. This act assured affordable health care coverage, managing care and also regulated competition among health insurance plans. Republicans and lobby interest groups heavily attacked Clinton’s plan; the deeply funded lobbying campaign against this plan spent in excess of $100 million to influence the policy outcome (Skocpol: 1995:19). Although the notion of national health insurance was essentially cast aside with the demise of Clinton’s plan, demands towards implementing health care reforms were revealed through ObamaCare.
Currently, over forty-eight million Americans remain uninsured and the figure is only rising. The Patient Protection and Affordable Care Act (ACA), commonly referred to as ObamaCare, was implemented in 2010 by the Obama Administration—representing one of the most significant overhauls of health care since Medicare and Medicaid. Obamacare was designed to reform the American health system through lowering the uninsured rate by expanding coverage and reducing the costs of healthcare, ultimately to increase health insurance quality and affordability. Since its implementation, twenty million Americans currently have health care insurance and successfully resulted in a major decline in the number of uninsured. Obamacare functions on the premise of providing cost subsidies to low and moderate-income earners and small businesses through the taxation of high-income earners and health care benefactors. Since the beginning of his tenure, Obama faced continuous challenges in implementing policies from the Republicans, especially health care reforms. Opponents of this act challenged the individual mandate that required people to purchase health care through Obamacare or a private entity. These oppositions were addressed in the Supreme Court case of National Federation of Independent Business v. Sebelius; the Supreme Court upheld the individual mandate, but the controversy endures. The policies of Social Security and Medicare were originally implemented and accepted more easily with less bipartisan support because in 1935 and 1965 Democrats not only controlled the White House but also had majorities in both the House of Representatives and House of Senate. In contrast, ObamaCare was hardly supported by Congress in 2010 as Republican forces heavily dictate the chambers.
The most common explanation for the absence of a national health insurance in the United States is because of its unique political culture (Jacobs: 1993:331). America has developed individualistic and anti-statist political values that have shifted the polity to be biased against the welfare state (Steinmo and Watts: 2005:329). The United States, a nation founded by immigrants in pursuit of freedom and opportunities, is a capitalistic nation where the main presumption of the economy is that the government intervenes if and only when markets fail (Grott: 2006:1). America exhibits a strong commitment to the values of individualism, limited national government, and anti-Statism. Americans have aimed to preserve the privilege of personal choice through constant adherence to liberal values and economic mechanisms. The health care industry defies many of the basic premises of private markets as the provision of goods and services are heavily regulated. Jacobs contends that the “enduring public ambivalence towards government…is the underlying source of America’s impasse” over health care reform (1993:630). Moreover, Skocpol argues that when reforms at universal health care fail, it enhances the distrust of the government by Americans, therefore maintaining the repetitive cycle of defeats which limits the likeliness of success for the next attempt at reform (1995:22). The strong commitment to an individualist culture has led to a lack of a working class movement and labor-based political party within the United States (Navarro: 1989:890). The commitment to individualism inclines to guilt the poor for their poverty, whereas in Europe, where poverty is deemed a societal not individual challenge. This inefficiency originates from the “power resource” theory where the welfare state in capitalist nations results from trade union mobilization. This theory represents an alternative for the mobilization of resources where private economic interests dominate and workers assemble into trade unions and utilize this power to expand the welfare state (Hicks: 1999:132). This theory acknowledges the politics employed when labor unions mobilize but fails to discuss the politics involved when markets remain key.
The lack of national health insurance in the United States portrays an aspect of its exceptionalism. In the context of health care, commercial enterprise has become the main mechanism for national health insurance plans. Nonetheless, this argument fails to account for the public opinion regarding modern American health care nowadays. Firstly, the culturist argument presumption that America will never implement universal health care due to anti-statist is too generalized. Although Americans hold these individualistic values, they are also profoundly egalitarian—especially vis-à-vis the value of equal opportunity (Steinmo and Watts: 2005:332). There are many cases that illustrate this contradiction such as the development of a publicly financed education where advocates argued similarly to health care reformers yet they were successful and effective. Secondly, the lack of comparative historical evidence reveals another flaw in the culturist argument. There is insufficient evidence to indicate that a capitalist culture is what separated the movements towards universal health care in Europe and the United States. The public health programs did not necessarily arise due to public demand but rather the ruling elite’s efforts in addressing policy issues (Immergut: 1992:111). Although the culturist arguments helps rationalize why health care is unpopular in that its fundamentals contradict capitalism, it is premised on assumptions that are too static and outdated.
Any history of the politics of health care reform in the United States elaborately demonstrates that reformers in the United States have faced an exceptionally well-organized and well-financed opposition (Steinmo and Watts: 1995:334). Unlike the culturist factor, this argument contends that the United States failed to create universal health insurance despite the public support for it. There are heavy opposition and great efforts to thwart health care reform from Republicans for numerous reasons. The funding and assistance from insurance companies to Republicans in exchange for their support influences their agendas. The opposition largely constitutes of private insurance lobby companies and their benefactors, whose main goal is to maximize profits resulting in the polarization between private insurance companies and American clients. Another factor, which proves another systematic deterrent to American health care reform, includes the distinctive characteristics of American political institutions, which have allowed for the opposition, mainly private insurance companies, to obtain control. The structure of American political institutions shaped the political strategies of both proponents and opponents of reform. Candidates running for office personally raise campaigns funds and thus are more susceptible to the interests and demands of lobbying organizations and private insurance companies. Decentralization thus impedes policy reform by increasing veto points where opponents can block any reforms by allowing lobby organizations greater access and influence. Ellen Immergut argues opponents of large-scale government entry into the health policies have generally been advantaged when a polity has numerous ‘veto points’, such as federalism and separation of powers between the executive and legislature (Immergut: 1992:139). This illustrates how the share of the government financed medical spending is correlated with the number of institutional veto points. This correlation has led to the emergence of “path dependency” theory, where it is argued that policies are not only enacted due to politics but also from widespread public beliefs and interests. The “path dependency” theory helps emphasize the significance of analyzing interests that emerge in response to policy innovation and thus the potential consequences of alternatives.
The power of private insurance companies was exemplified during the Truman administration’s brief encounter with promoting national health insurance in 1945. The AMA, representing physicians, conducted an opposition campaign, the “National Educational Campaign”, to not only impede its enactment but also endorse private health insurance. AMA national headquarters instructed members to assemble into campaign organizations in order to “keep public opinion hostile to national health insurance” and elicit an antistatist theme—that national health insurance was ‘socialized medicine’, part of a Communist plot to destroy freedom (Quadagno: 2004:30). The AMA actively engaged in politics, opposed supporters of health coverage and collaborated with insurance groups such as pharmaceutical and drug manufacturers in promoting private health insurance through objecting national health insurance. The AMA successfully and effectively mobilized resources to produce an effective campaign. The AMA succeeded in organizing other anti-welfare state groups into coalitions to expand their oppositional message across. In 1945, seventy-five percent of Americans supported national health insurance; by 1949, supporters had declined to only twenty-one percent (Quadagno: 2004:30). Many argue the absence of an opposing force allowed AMA to mitigate support for their concerns incorporating it into the policy making process, however, it is rather evident that many of their interests coincided with those of other insurance companies which allowed for them to expand their power. It is insurance companies such as the AMA and Health Insurance Association of America (HIAA), representing for-profit insurance firms, which worked towards political strategies that defined private medical health care as a high-cost, corporate model found on insurance-company funding and management (Hacker: 2004:126). Surges in medical costs caused insurers to gradually extend their authority over health care; through which, insurance companies expanded their role to nowadays, controlling medical processes.
The third argument is that the United States lacks universal health care because it lacks a successful model from elsewhere to emulate, as the health services in Europe have generated extremely high costs. With the exception of the United States, the right to health care is officially incorporated in the constitutions of many developed nations. The United States continues to remain the only Western industrialized nation lacking a comprehensive universal health care and yet generates much higher medical costs and spending than any other nation. In Europe, a single-payer system are the conventional forms of health care programs, whereas the United States utilizes a multiplayer system where the federal and state governments and private health insurance companies are the key health care providers. Many of those who oppose universal health care in the United States argue that the health care systems in Europe are filled with issues ranging from long delays and waiting lines, high costs to free riders. Republicans argue national health insurance will place a larger financial burden upon the federal government. Republicans justify this view claiming the most compelling argument that costs will result too expensive for a nation that already spends more than any other in health care. OECD figures indicate that the United States spent 17.1% of its gross domestic product on health care in 2013 (OECD: 2013).
Nonetheless, this argument fails to acknowledge the recognition of the benefits stemming from health care in Europe by Americans. Although there are great exaggeration and manipulation tactics employed by Republicans in depicting the inherent failure of the system, this factor is not convincing enough in justifying all its controversy. The fact that the United States spends more of its GDP on health services than any other nation yet still fails to ensure all its citizens is indicative enough that the United States is nowhere near as effective and thus in need of reform. Moreover, this argument fails to recognize the fact that it is impossible for the United States to implement a model emulating the health care systems in Europe, as it would prove ineffective in the United States
Trump’s victory in the 2016 election coupled with the establishment of Republican control in both chambers of Congress has dramatically shifted the direction and implications of health care reform in the United States. Throughout his campaign, Trump supported the repeal and replacement of ObamaCare through which he gained secured support from the Republicans. The Trump administration very recently devised a health care plan legislation, known as the American Health Care Act (AHCA), a bill which the House is expected to vote on this week. In order to appease conservative lawmakers, House Speaker Paul Ryan and Republicans are providing states with the ability to require healthy Medicaid recipients to work, a provision which Republicans have long pursued. Moreover, the current legislation permits the option to receive federal Medicaid funding as a block grant for states. It also provides states with a per capita cap system. These new policies would represent a major change from the way Medicaid is currently funded, which is unlimited federal support associated with state spending on the program. In its evaluation, the Congressional Budget Office predicted this bill would reduce federal deficits by $377 million and increase the number of uninsured to fourteen million people in 2018 and twenty-six million in 2026 (CBO: 2017). Ironically, under the AHCA, lower-income Americans living in rural areas—those who would broadly categorize themselves as Trump supporters—are those whom will be most negatively affected.
The lack of a comprehensive universal health care coverage in the United States proves detrimental to the economy and productivity of the nation. Health care coverage in the United States nowadays is a privilege, not a right. However, for those in need of insurance, it is a matter of life and most likely, death. The majority of those unable to access health insurance are the working class unable to pay private insurance companies and subsequently die due to lack of access to health services; A study carried by Himmelstein and Woolhandler demonstrated this where “approximately 100,000 Americans died annually due to the lack of needed care—three times the number of people who died of AIDS” (1997:11). All the factors discussed throughout—the capitalist culture of the United States, heavy opposition from insurance companies lobbies, and a lack of a successful model due to the drawbacks of the current health care systems in Europe—have all contributed to the unpopularity regarding the implementation of universal health care in the United States. The capitalist culture is heavily embedded in American politics and as its fundamentals contradict the essence of a national health care system, many from the opposition utilize this factor to obstruct any health care reform. The minor failures from health care, mainly high costs, in Europe is manipulated and exaggerated by the opposition to portray an image that national health care is ineffective and doomed. Nonetheless, the power of the opposition has always proved to be the most influential force in contributing to the controversy regarding health care, exhibited during the presidencies of Roosevelt, FDR, Truman, Johnson, Clinton, and Obama—thwarting any progress regarding this matter. Although Obama against all odds proved to be successful in implementing Obamacare, its future and the future of universal health care in the United States will likely be dictated by Republicans, whose strong ties to private insurance companies foreshadow a never-ending debate regarding the long awaited implementation of universal health care.