Almost all the presidential candidates for 2020 have a strong opinion on how to reform health care delivery in the United States. Almost none of them completely agree on how that reform needs to take place. This raises a pertinent question: How can health care be made affordable for everyone in the United States, given the country’s preferential economic philosophy of free markets?
To understand the extent of inequity in the delivery of health care is in the U.S., one just needs to look at the number of patients leaving the country for care and for those staying, the number of patients starting campaigns to fund their health care needs. For instance, each year more than a million Americans travel overseas for health care–related purposes as they are often priced-out of the health care market.
While high-income patients have a variety of options and can pay out-of-pocket for their care, this is impossible for most American patients in the current atmosphere of income inequality. Average health care spending per-person in the U.S. was $10,224 in 2017, which is almost double that of comparable industrialized countries ($5,280). To put that burden in context, the median 2017 household income in the U.S. was $61,372.
What do Americans do then if they cannot afford the high cost of health care?
Some may choose not to get help. Clinical research has shown, unsurprisingly, that patients delay seeking care when they do not have enough financial resources to receive the medical care they need—even in states with an insurance mandate, for instance Massachusetts.
Others may seek help online. A recent report by Kaiser Health News revealed that the crowd-funding website GoFundMe hosts more than 250,000 campaigns every year to pay for medical expenses. Think about that statistic for a moment. The report highlighted these campaigns constitute one third of the total donations (approximately $5 billion) received by the website. While these numbers may seem absurd by the standards of any other developed country, financially strapped vulnerable patients in the U.S. have to navigate this quagmire on a daily basis.
As a public health analyst, I have repeatedly highlighted how structural impediments within the American health system exacerbate inequities; financial toxicity is one of the most important factors. Universal health coverage could help make health care more affordable for those who need it. However, usually, analysts who oppose health care–for-all policy have two arguments: economic wastage from higher costs and conflict with American values.
The economic waste argument asserts that health-for-all would lead to people seeking unnecessary medical care and catapult the system towards an uncontrollable higher costs. In economics, this idea is called “moral hazard”—defined by some as the idea that people insulated from risk behave differently than people exposed to risk. The problem is, applying this objection in health care is not as straightforward, because it is rare for someone to look forward to ending up in a hospital.
Last year, an analysis by colleagues at Harvard’s Chan School of Public Health illustrated how hyperutilization of medical services was not the only reason for high health care spending in the United States. In fact, patients in the U.S. use health services (measured by visits to a doctor, for example) less than average when compared to other wealthy nations. It is higher prices, not quantity, of seeking medical care and pharmaceutical drugs that drive higher spending—leading to more wastage.
The second argument—that health-for-all policy is in direct conflict with American values—is evolving. Values of freedom and equality are enshrined in the U.S. Constitution. Given the country’s history—from the women’s suffrage movement to the civil rights movement—people have always sought (and demanded through political action) policies that correct historical misjudgments and lead to a more equitable society. Recent polls on this issue demonstrated that 70 percent of voters, including more than half of Republican or right-leaning voters, support policies that advance health care for all. Thus, these two main reasons against universal health care really aren’t strong enough to overcome the positives.
To be sure, it is unlikely that the American health care system will ever be completely socialized. Similar to the health system in Canada, it will likely be a system that combines public and private funding options for health care. Given the country’s value system, a system where people are free to choose will likely prevail. In addition, for those who seek exclusivity or services that are costlier than usual, paying extra would be an acceptable option as well.
In a moral society, the balance of people’s bank accounts should not determine their ability to seek medical care. However, we will not get to that place of discussion unless we have honest conversations about the limitations of the current health system. Politicians often frame the health care debate in this country in terms of freedom. It is time that they engage in conversations that allow every patient to exercise that promised freedom.