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Universal Health Coverage from the World Stage to National Health Reform

One day before the end of the open enrollment period to gain coverage under the Affordable Care Act (ACA), a federal judge ruled the ACA as unconstitutional [1]. Judge Reed O’Connor of Fort Worth, Texas struck down the law last month on the basis that the individual mandate “can no longer be sustained as an exercise of Congress’s tax power.” He further ruled that the remaining provisions of the ACA are invalid without the individual mandate.

Twenty states, led by Texas, brought forth the lawsuit against the ACA [1]. Although the Justice Department disagreed with the entirety of the ruling, it declined to defend the law’s individual mandate and protections for preexisting conditions. Rather, California in an alliance with 16 states and the District of Columbia, has taken the lead to appeal the court’s decision. If the appeals court upholds the ruling, millions of Americans who gained health insurance under Medicaid expansion will lose coverage.

In light of Judge O’Connor’s decision, advocates of “Medicare-for-all,” have pushed their support for a single-payer system [2]. Topher Spiro, Vice President for Health Policy at the Center for American Progress, voiced that the lawsuit proves how Obamacare has “too many points of vulnerability.” Lawmakers from Illinois, California, Vermont, and Oregon have agreed with Spiro’s position on the basis that “Medicare is already constitutional” and by extending it to everyone, “there can be no constitutional argument.” Senator Elizabeth Warren, who announced her 2020 presidential bid, has supported this position and recently endorsed the Medicare-for-all bill drafted in the Senate by Senator Bernie Sanders [3].

It is no surprise that healthcare reform continues to make national headlines. A 2018 study by JAMA found that the United States spent twice as much as other high-income countries on healthcare, despite equal utilization rates [4]. Out of 11 OECD countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark), the US had the lowest life expectancy (78.8 years compared to a mean of 81.7 years) and the highest infant mortality (5.8 deaths per 1000 live births compared to 3.6 per 1000). The study found the major cost difference between the US and other high-income countries rested in the price of labor and goods [4].

Another key difference between the US and the other countries that the study did not highlight in their conclusion is universal health coverage for citizens. While a philosophical debate remains as to if universal health coverage (UHC) can function in a country as big as the US, placing UHC into a more global context may help guide reform at home.

The foundation for our modern idea of UHC can be traced back to the 1978 Declaration of Alma Ata [5]. In their statement, the World Health Organization defined health as “complete physical, mental and social well being, and not merely the absence of disease or infirmity.” Moreover, they affirmed that health is a fundamental human right, and attaining the highest possible level of health is a top priority for all countries. At the same time, the Cold War between the United States and the Soviet Union was shaping the world. In the US and the West, the idea of adopting healthcare as a fundamental human right seemed like a Soviet effort to propagate Socialism.

Since then, attitudes surrounding UHC have changed. Canada and the UK both have single-payer systems, although the role of government differs between the countries [6]. Still, single payer does not necessarily mean UHC. So, how is UHC actually defined?

The WHO defines universal health coverage as a system where “all people have access to the health services they need (prevention, promotion, treatment, rehabilitation and palliative care) without the risk of financial hardship when paying for them.” Additionally, the WHO lays out three objectives related to UHC [7]:

1.     Equitable access to health services: everyone who needs services should get them, regardless of their ability to pay for those services
2.     Quality of health services: a minimum standard is necessary to improve the health of those receiving services
3.     Affordable health services: the cost of using health services should not put people at risk of financial harm

Adopting UHC has continued to gain traction on the world stage, especially with its spotlight in the Sustainable Development Goals (SDGs). The United Nations adopted the SDGs in 2015 as an “urgent call to action by all countries” in moving towards global peace and prosperity [8]. Goal 3 of 17 specifically addresses UHC: to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”

According to the WHO, achieving UHC requires a “strong, efficient, well run health system [9].” They also recommend that countries can best finance UHC through taxes or compulsory earmarked contributions.

The resolutions brought forth by the WHO and the UN suggest that universal health coverage is guiding international health reform. The question remains as to if the US will follow the global trend or push national health reform in another direction. The lawsuit against the ACA does highlight its susceptibility to repeal and places doubt upon the longevity of the policy. With the new members of the 116th Congress recently sworn in, healthcare reform will persist as a contentious issue in our country. Regardless of political leaning, universal health coverage in the form of Medicare-for-all will undoubtedly make an appearance in the conversation.

Tina Samsamshariat

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Tina Samsamshariat is a member of the class of 2022 at the University of Arizona College of Medicine - Phoenix. She received her Bachelor of Science from the University of California, Los Angeles and her MPH from the University of Southern California. She enjoys surfing, climbing, and rap music. Twitter: @TSamsamshariat

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