Editor’s Note: Dr. Abdul El-Sayed is a physician, epidemiologist and former health director for the City of Detroit. Dr. Micah Johnson is a resident physician at Brigham & Women’s Hospital in Boston, Massachusetts. They are co-authors of “Medicare for All: A Citizen’s Guide.” The opinions expressed in this commentary are their own.
While the pandemic has put immense stress on nearly every country’s health care system, no country — and certainly no other high-income country — has suffered the way the United States has. Americans make up less than 5% of the global population, but account for nearly one in five of the world’s 2.3 million deaths. All the more astounding is that as the richest, most powerful country in the world, its overwhelming resources did nothing to help absorb the shock of an event like this.
There are, of course, many reasons why America suffered Covid-19 worse than any other country in the world, including failed political leadership, a concurrent epidemic of disinformation and flagging public trust. But the way the United States approaches health care is high on the list.
President Joe Biden was elected on a platform that focuses on improving the Affordable Care Act, but the ACA left tens of millions of Americans uninsured in the middle of a pandemic and millions more afraid to get care if they got sick. If the nation is serious about learning the lessons from this pandemic, it should reconsider implementing a universal health care plan like Medicare for All.
America’s health care system is the most expensive in the world, accounting for nearly 18% of overall gross domestic product. It is also a business, which means that hospitals have to remain profitable to remain open, always conscious of the bottom line. Elective procedures offered to privately insured patients are one of the most important revenue streams in American health care. When hospitals were forced to cancel these elective procedures early in the pandemic, they were left without that revenue, battling Covid-19 and bankruptcy at the same time.
Had a universal health care plan been in place, hospitals wouldn’t have been so financially ruined because they’d be getting paid fairly for treating all patients. They wouldn’t have had to rely so heavily on privately insured patients getting pricey elective procedures. President Biden’s plan to expand the ACA would not solve this problem because it would keep some Americans on private insurance and other Americans on Medicare and Medicaid, meaning that doctors and hospitals would continue to get paid more for treating privately insured patients and therefore keeping the incentive for healthcare providers to cater to them disproportionately.
On the other side of the health care industry sits health insurance. With many patients avoiding care during the pandemic — elective or otherwise — insurance companies haven’t had to fork over as many reimbursements, and as a result their profits appear to have increased in 2020.
And because about 150 million Americans are insured through their employers, an economic downturn that spikes job losses (like the one that hit last spring) usually leads to millions of people being kicked off their health insurance. That is exactly what happened at the beginning of the pandemic: Millions of Americans lost their private insurance. Because the ACA maintained the central place of job-based health insurance, millions of Americans were left exposed during the coronavirus recession. With a universal health care program like Medicare for All, health insurance would be a right instead of a job perk, and no one would have lost their insurance in the middle of the pandemic.
While the United States spends heavily on lucrative industries like insurance, hospitals and pharma, only a tiny fraction of our health spending goes toward improving public health. The problem of chronic underinvestment in public health and prevention has become clear in the midst of this pandemic, as the nation’s anemic public health infrastructure is tasked with deploying millions of doses of vaccine in record time, leading to the failures we’re witnessing now. Worse, because there are hundreds of health insurers in the United States and plenty of people jump between insurers, no one insurer has an incentive to invest in preventing disease. The savings of investing in preventing diseases early (when people don’t develop those diseases) usually accrue years later after a given beneficiary has moved on to a different insurer.
But under Medicare for All, the federal government would insure Americans yesterday, today and tomorrow, so there is plenty of incentive for government to invest in public health and prevention infrastructure — the kind of infrastructure so critical in executing mass vaccination campaigns. These long-term incentives simply aren’t there under the ACA, with hundreds of competing insurance companies jockeying for enrollees and profits.
Politicians and pundits will offer piecemeal solutions. But there is no doubt that the best way to have addressed each of our system’s deficiencies in one reform would have been through a universal national health insurance program such as Medicare for All.