After Universal Health Coverage

In Health Care Reform, Inequality, Politics of Policy, Poverty, Public Policy, Social Democracy, Social Policy, Welfare State on September 12, 2009 at 11:17 am

labour poster 1945 2


The sad truth of the American health care debate is that all we get to do, all we get to talk about, all we fight over is how to pay for things. We don’t actually talk about health care itself very much. Given the intensity of the current debate, the sheer amount of mental and physical and emotional energy that is required to keep pushing through every challenge and setback, this is understandable.

However, it is crucially important to think about what comes after universal health care. Because, as any European who’s engaged in politics will tell you, the politics of health care do not end at the mere provision of access – there is an entire politics that emerges afterwards, a politics about quality of care, about comprehensiveness of services, about the actual impact of health care on our health.

And we have to get ready for that politics.

After Universality:

Despite the fact that recent statistics have shown that the number of uninsured have increased by six million in the last year and that half of Americans can expect to lose their health care over the next ten years, and that health care costs are rising at 2% faster than GDP, America’s worst health care statistics might be our actual outcomes, given the sheer amount of money we spend on health care.

And one of the virtues of a universal health care system, in addition to coverage and cost containment, is that you can actually focus the public policy debate on health care to outcomes. This creates an opportunity to focus public attention at those areas of health where America has truly fallen behind, and then take some of the money saved from achieving universality and investing it in efforts to actually improve the well-being of Americans. And indeed, this is how health care politics often works in countries with universal health care – the focus shifts to cures and treatments, on efforts to eradicate diseases and improve public health, to save lives and improve the quality of life.

What to Target:

  • Child Mortality – one of America’s greatest failures as a society is our child mortality rate. In the United States, 8 children per thousand live births won’t survive to their fifth birthday – this is the worst among all OECD (developed) nations; by contrast, Sweden’s child mortality rate is only 3.25. In other words, in the U.S every year 19,000 children will die before their fifth birthday who would be alive if they had been born in Sweden. And this enormous disparity is largely driven by economic inequality – poor children don’t get fed as well as well-to-do children, and they don’t get to go to specialist pediatricians for checkups and preventative care, instead they get the emergency room when they get really sick.  Why not invest some of the savings into challenging Sweden’s position for the lowest child mortality in the world – after all, a large amount of child deaths in the U.S are preventable.
    • Incidentally, this is one of the reasons why, even in a system of universal health coverage, a supplementary system of free, high-quality prenatal and pediatric health care should be a “next target” for progressive health care activists.
  • Medically Preventable Death – alongside child mortality, medically preventable deaths seem like an obvious place to start improving American health outcomes. While we know that, for example, 22,000 people a year die due to lack of health coverage, which presumably would be eliminated by universal coverage, and while the current health reform effort’s emphasis on making routine checkups and preventative medicine free will also help, it will still be necessary to invest heavily in public health to further reduce the 750-101,000 deaths a year caused by medically preventable diseases. Furthermore, a focus on improving safety standards in our hospitals could further reduce the 44-98,000 deaths a year caused by medical errors in hospital. Saving as many as a quarter million lives a year looks like a good investment in health to me.
  • Highest Killers – the ten highest causes of death in the U.S, in order, are heart disease, cancer, stroke, chronic respiratory diseases, accidents, diabetes, Alzheimer’s, influenza and pneumonia, nephritis, nephrotic syndrome, and nephrosis, and septicemia. Now some of these – accidents, for example – we can’t really do anything about beyond urging people to be safer. But most of the diseases on this list are all treatable if not curable, and one of the things that should be done after universality is to put significant public resources into efforts to combat these diseases, combining public health, scientific research, and other resources.
  • Life Expectancy and After – given the looming presence of the baby boom’s retirement, it’s unsurprising that eldercare should have a prominent position here (personally, I think people are overlooking what will happen when the “baby boomlet” comes of age, given that it’s substantially larger than the baby boom). However, the amount of medical attention that’s being paid to the diseases of the elderly is quite sufficient – where I think public investments could make a difference is pushing the focus away from just looking at extending years of life to extending years of competency, which would involve focusing on the earlier problems of the aging process, as opposed to the manifest medical problems that crop up at the end. Moreover, I think further research into the brain and the mind and ways is absolutely necessary, because one of the cruel ironies of advances in medical science is that our bodies are starting to outlive our brains – we need to work harder on restoring some sort of balance there, so that the end of our years can really be ones of dignity and enjoyment.


This list is really intended to start a conversation, not finish it, and to redirect our thinking for a second from the way we pay for health care to why we pay for health care. Because the ultimate purpose of all of this is to improve the general welfare of the American people, and with all apologies to President Obama, that is not a fight that ends. When we finally achieve basic medical coverage for all, we will still need to extend visual and dental coverage, and America’s mental health system is also in terrible shape.

When Ted Kennedy said that “the dream shall never die,” he was not merely referring to the endurance of political ideology through long periods of helpless opposition. He was also referring to the fact that each victory merely changes the battleground on which we fight. And don’t think for a second that any of the things above will be an apartisan or apolitical battle – there will be huge pressures, on the day after universal health coverage is actually passed, to say that we should stop there and go no further, that there is no longer a health care issue.

But that’s a battle I would be happy to fight.

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  1. […] I’ve stated on previous occasions, one of the most fundamental changes that comes with the passage of the […]

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