I was doing a bit of prep this week for my Fall 2012 class, Intro to the U.S. Health Care System. I have taught it many times, and I am trying to decide how to put what has happened the past three years into perspective for 19 year olds (with a big shoe left to drop next week).

A reporter from another country interviewed me this week and asked “why doesn’t the U.S. have a universal system of health insurance coverage?” From 1999-2008, I gave roughly the following answer:

  • Because organized medicine has always opposed reform efforts
  • Advocates have failed to make the case to the “middle class” that reform was in their best interest (and efforts to do so were always portrayed as giveaways to the poor)

Of course many professional and industry groups who had historically opposed reform supported the ACA, so that was very different this time. And the arguments for why coverage expansions were important also changed. I perceive that advocates for health reform made a much more forceful argument about the economic costs of the uninsured to those with insurance during the ACA debate. There were fewer appeals to (moving toward) covering everyone because it was the morally correct thing to do, and more energy was expended to make the “business case” that the insured were already paying through cost shifting, so we might as well do so in a more straightforward fashion.

Paradoxically, as advocates honed the ability to make this case rhetorically, there was emerging evidence that cost shifting may not be as large as once thought, and that spillover effects may actually work in the opposite direction if there are coverage expansions to low income persons (actually the theoretical notion was from a 1994 book by Michael Morrissey, but more empirical work was coming about). This doesn’t mean there is not a cost shifting effect: in fact regardless of any actual economic impact of cost shifting, there is most certainly a political or negotiating effect (if I run a hospital, my answer to why I can’t take a lower price from a private insurance company will be cost shifting, regardless of what the magnitude actually may be; and hospital systems are gaining market power).

However, this type of discussion–what amount of money is shifted to the premium of the insured, and even the opposite argument of spillover effects via coverage expansions of low income persons that may benefit the privately insured, actually obscures the human face of persons not having coverage as the reason to move toward universal coverage.

It seems that in some past reform efforts advocates may have only focused on the morality of moving toward universal coverage. In the latest round, more nuanced economic arguments were more successfully advanced, but the main reason to develop a universal insurance system may have been lost in the shuffle.

[Cross-posted at The Reality-based Community]

Don Taylor

Don Taylor is an associate professor of public policy at Duke University, where his teaching and research focuses on health policy.