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Towards Universal Health Insurance in the United States?

ARTICLES - 22 March 2019

Health was a central issue in the midterm elections of November 2018, which seemed to mark the end of years of controversy over the Affordable Care Act known as Obamacare. New themes are now at the forefront of health discussions in the United States. Angèle Malatre-Lansac, our Associate Director in charge of Healthcare Policy, works with the  Rand Corporation and Harvard Medical School on the American healthcare system. She analyses for us the current health issues in the United States.

The United States is one of the only major developed countries without a national health insurance system. About half of Americans have private health coverage through their employer, 7% are individually covered, 14% are covered by Medicare, the federal insurance for people over 65 and disabled and 20% of low-income Americans are covered by Medicaid. 9% of the population remains without health insurance to this day.

9% of the population remains without health insurance to this day.

This situation is the result of the 2010 Obamacare, which enabled 8% of Americans who previously had no health coverage to obtain insurance through the market system. Obamacare has made it possible to increase the number of people covered without fundamentally changing the system, which is still based on the principle of private insurance.

Today, the debate seems to have reached a new level on the Democrats’ side. Now that Obamacare seems no longer under threat, the Democrats are preparing for the 2020 elections by competing with proposals for extended, even universal health coverage; an idea hitherto reserved for the party's far-left fringe, represented by Bernie Sanders.

On the Republican side, this idea is completely rejected, but the party is struggling to find a promising theme around health since the failure of the "Repeal and Replace Obamacare". In his State of the Union speech on February 5, Donald Trump mentioned health several times, but seemed to have definitively buried one of his main campaign proposals: the end of the Obamacare. Conservative groups are looking to position themselves and one of the possible options would be to build proposals around the importance of federalism and the role of states in health innovations ("The state innovation approach").

"Medicare-For-All": an unlikely policy at the heart of the future Democratic primaries

Despite the Affordable Care Act, 28 million Americans continue to have no medical coverage, and many insurance policies offer only very minimal coverage. Implementing a "Medicare-For-All", named after the health insurance for the elderly managed by the American federal government, could enable the entire population to have their medical care covered.

he pre-campaign for democratic primaries has begun, and proposals around this broad or universal coverage are multiplying, acting as a test for 2020. The debates are intense, and the variations range from a simple improvement of the Obamacare which would guarantee private insurers their place in the system (this is the purpose of the "Medicare for America" proposed in December 2018 by Congresswomen Rosa DeLauro and Jan Schakowsky), to Bernie Sanders' proposal to set up a fully public single payer system. As a result, private insurers would disappear in their current role.

28 million Americans continue to have no medical coverage, and many insurance policies offer only very minimal coverage.

The idea is popular and 56% of Americans would support a Medicare-For-All according to a recent survey by the Kaiser Family Foundation. Few of them, however, know how to define what is behind this proposal or how to finance it. And the oppositions are numerous and powerful: private insurers like the pharmaceutical industry do not see their interest in it and doctors' associations like the powerful American Medical Association are concerned about a state takeover of the health system. Or even a "socialization of medicine". While there is a strong debate on the subject, the concrete realization of such a change seems unlikely.


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