Universal Health Insurance in the United States: Reflections on the Past, the Present, and the Future

We used to say that the United States shared with South Africa the distinction of being the only industrialized nation without universal health insurance. Now we don’t even have South Africa to point to. Almost 20% of the nonelderly population in this country lacks health insurance at any given time, and the disparities in access to care and health outcomes are very much greater in the United States than anywhere else from which there are reasonable data.

It is relevant to the politics of health care that the high end of the American health care system compares favorably with that anywhere in the world. Some significant fraction of all the total knee replacements in the world are performed in the United States. If you live in certain urban areas and you develop certain tumors, you will get the most sophisticated and advanced treatment anywhere in the world and have outcomes that are at least comparable to those anywhere. But there are considerable pockets of the population for whom access to health care and the effects on health status are much more similar to those of poorer and less successful Third World countries than they are to those of the rest of the industrial world.

It is not as though these disparities are saving us any money: by any measure, we spend substantially more on health care than any other nation. Indeed, we spend more money on health care for Americans aged 65 years and older than is spent for the entire population of any other nation.

So the United States is by international standards quite peculiar, and the question is why. This is not just an academic question; to understand how to move effectively toward universal health care in the United States, it is essential to understand how we got to where we are. Freud said that all psychiatric phenomena are overdetermined; that is, there are more explanations than you need to produce the outcome, and that is probably true of most of the social sciences as well. I have identified 10 explanations for why the United States is so peculiar, all of which are true—and any one of which by itself would probably be a sufficient explanation. These explanations fall into two broad categories: historical-cultural and structural-political.

Source : https://www.usa.gov