Several hundred cars were parked outside a food bank in San Antonio on Good Friday — the food bank fed 10,000 people that day. Such scenes, increasingly common across the nation and evocative of loaves and fish, reflect the cruel facts about the wealthiest nation in the world: 80 percent of Americans live paycheck to paycheck, and 100 percent of Americans were unprepared for the COVID-19 pandemic. People are hungry due to macroeconomic and environmental factors, not because they did something wrong. Although everyone is at risk in this pandemic, the risk is not shared equally across socioeconomic classes. Universal basic health care could resolve this disparity and many of the moral and economic aspects associated with the pandemic.
Increases in the total output of the economy, or the gross domestic product (GDP), disproportionately benefit the wealthy. From 1980 to 2020, the GDP increased by 79 percent. Over that same time, the after-tax income of the top 0.01 percent of earners increased by 420 percent, while the after-tax income of the middle 40 percent of earners increased by only 50 percent, and by a measly 20 percent for the bottom 50 percent of earners. At present, the top 0.1 percent of earners have the same total net worth as the bottom 85 percent. Such income inequality produces poverty, which is much more common in the U.S. than in other developed countries. Currently 43 million Americans, or 12.7 percent of the population, live in poverty.
At the same time, 30 million Americans are uninsured and many more are underinsured with poorly designed insurance plans. The estimated total of uninsured and underinsured Americans exceeds 80 million. In addition, most of the 600,000 homeless people and 11 million immigrants in the U.S. lack health care coverage. Immigrants represent an especially vulnerable population, since many do not speak English and cannot report hazardous or unsafe work conditions. Furthermore, many immigrants avoid care due to fear of deportation even if they entered the country through legal channels.
Most people in poverty and many in the middle class obtain coverage from federal programs. On a national level, Medicaid is effectively a middle-class program and covers those living in poverty, 30 percent of adults and 60 percent of children with disabilities as well as about 67 percent of people in nursing homes. In Iowa, 37 percent of children and 48 percent of nursing home residents use Medicaid. Medicaid also finances up to 20 percent of the care provided in rural hospitals. Medicare, Medicaid and the Children’s Hospital Insurance Program (CHIP) together cover over 40 percent of Americans.
In addition to facilitating care, health care policy must also address the “social determinants of health,” since the conditions in which people live, work, and play dictate up to 80 percent of their health risks and outcomes. This means that health care reform requires programs in all facets of society. Winston Churchill first conceptualized such an idea in the early 20th century as a tool to prevent the expansion of socialism, arguing that inequality could persist indefinitely without social safety nets. Since that time most developed countries have implemented such social programs, but not the US.
All developed countries except the U.S. provide some type of universal basic health care for their residents. Universal basic health care refers to a system that provides all people with certain essential benefits, such as emergency services (including maternity), inpatient hospital and physician care, outpatient services, laboratory and radiology services, treatment of mental illness and substance abuse, preventive health services (including vaccinations), rehabilitation, and medications. Providing access to these benefits, along with primary care, dramatically improves the health of the community without imposing concerns regarding payment. Perhaps not coincidentally, the U.S. reports a lower life expectancy and higher rates of infant mortality, suicide and homicide compared to other developed countries.
Countries such as Canada, Great Britain, Denmark, Germany, Switzerland, Australia, and Japan all produce better health care outcomes than the U.S. at a much lower cost. In fact the U.S. spends about twice the percentage of its GDP on health care compared to these countries. With that being said, the Affordable Care Act of 2010 (ACA), which facilitated a decrease in the rate of the uninsured in the U.S. from 20 percent to 12 percent, also decreased the percentage of the GDP spent on health care from 20.2 percent to 17.9 percent in just 10 years. For this reason, most economists agree that universal basic health care would not cost more than the current system, and many would also argue that the total costs of the health care system cannot be further reduced unless everyone has access to basic care.
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Achieving successful universal basic health care requires a serious long-term commitment from the federal government — contributing to Medicaid and financing its expansion are not enough. It requires courage from our elected leaders. The ACA took several important steps toward this goal by guaranteeing coverage for preexisting conditions, banishing lifetime maximums for essential services, and mandating individual coverage for everyone, though Congress repealed this final provision in 2017. At present, the ACA requires refinement and a public option, thereby preserving private and employer-based plans for those who want them.
Without universal basic health care the people living at the margins of society have no assurances that they will have access to basic health care services, especially during times of pandemic. Access to food and medications is less reliable, large families live together in small spaces, and public transportation facilitates frequent exposure to others. Childhood diseases such as asthma, chronic diseases such as diabetes, and diseases related to smoking such as COPD and cancer are all likely to worsen. Quarantine protocols also exacerbate the mental health crisis, further increasing rates of domestic violence, child abuse, substance abuse, depression, and suicide. In the last six weeks over 30 million Americans have applied for unemployment benefits, and as people become unemployed, many will lose health insurance.
Access to basic health care without economic or legal consequences would greatly enhance all aspects of pandemic management and response, from tracing contacts and quarantining carriers to administering tests and reinforcing supply chains. The COVID-19 pandemic has disproportionately affected minorities and the impoverished in both mortality and livelihood. Universal basic health care helps these vulnerable populations the most, and by reducing their risk it reduces the risk for everyone. In this way, universal basic health care supports the best interests of all Americans.
Like a living wage, universal basic health care aligns with the Christian tradition of social justice and is a moral and economic imperative for all Americans. Nurses, doctors, and other health care providers often observe a sharp contrast between the haves and have-nots when seeing patients. The homeless, the hungry, the unemployed, the working poor, the uninsured; people without families, patients with no visitors, those who live alone or lack support systems; refugees and immigrants — all of these people deserve the fairness and dignity provided by universal basic health care and programs which improve the social determinants of their health. The ACA moved U.S. toward this goal, but now it requires refinement and a public option. The COVID-19 pandemic highlights the urgency of this imperative by demonstrating how universal basic health care could decrease the risks to those less fortunate, thus significantly decreasing the risks to everyone.
James M. Levett, MD, serves on the board of Linn County Public Health and is a practicing cardiothoracic surgeon with Physicians’ Clinic of Iowa. Pramod Dwivedi, MS, DrPH (c), is the health director of Linn County Public Health.