The recently inaugurated president of the USA threatens to dismantle the largest health reform in a quarter of a century.
There can hardly be any doubt that the USA has some of the best hospitals, some of the brightest minds and the newest technology in the world. However, most of us here in Norway agree that in matters of health policy we should not look to the USA. This huge country has no nationally organised health system, and the size of your wallet decides the amount of healthcare assistance you may receive. The reasons include a conglomerate of private and public health service providers and insurance companies (1). The incentives reward overdiagnosis and overtreatment, and the administrative costs are astronomical. The USA spends by far the most of all Western countries on health (2). This notwithstanding, in 2010 one-fifth of its inhabitants had no health insurance (2). If you have insufficient or no health insurance, serious illness can become a personal and financial disaster. The most common cause of personal bankruptcies in the USA is illness-related costs (3).
The health-policy debate in the USA highlights a number of key issues that are relevant to our domestic debate as well. Is health a commodity that can be purchased like any other commodity or service? Is health a public good for which the government should be responsible and fund from tax revenues? Is health a right, something to which everybody is entitled, irrespective of their personal finances, status, insurance policy or citizenship, or should we only receive those services that we pay for?
Throughout the 1900s many attempts were made to establish publicly funded insurance schemes in the USA. The American Medical Association (AMA) fiercely opposed all of them – because they believed that this would restrict the freedom of doctors (4). When Franklin D. Roosevelt made an attempt in the 1930s, it was branded as socialism by the AMA, which spearheaded the resistance. After the Second World War, a universal health system was originally included in the plans for the New Deal (4). This led the AMA to hire an advertising firm. The slogan produced by the firm – «socialised medicine» – has since been used as an invective against all those who propose more public funding (5).
The absence of a national health system paved the way for private solutions, initiated by employers who purchased insurance for their employees. In 1950, one-half of the US population was covered by such health insurance, and by 1970 the proportion had grown to 70 %. It gradually became clear, however, that this system created gaps that some people fell through. When John F. Kennedy attempted to put a public solution in place, The AMA hired the young actor Ronald Reagan for a campaign that targeted the country’s housewives (6). Kennedy failed, but in 1965 Lyndon B. Johnson finally succeeded in establishing two public insurance schemes for those who needed them most: Medicare (healthcare assistance for people older than 65) and Medicaid (healthcare assistance for the disabled and the poorest segments).
In the 1970s the debate continued over accelerating health costs and insufficient access to services. The AMA would come to see that it was the private insurance companies, not the government, that robbed the doctors of their freedom by introducing the much-detested «managed care», the private version of New Public Management, in the 1980s.
In the early years of the new millennium, dissatisfaction was rife. Approximately one-fifth of the population had no access to health services. The insurance companies attempted to reduce their risk by denying insurance to people with a pre-existing condition or who were at risk of illness. Barack Obama opted to go for another solution than his predecessors by providing subsidies to those who purchased health insurance in the private market. According to this reform, which goes by the name of Obamacare, subsidies were also granted to those states that were willing to lower the threshold for inclusion in public insurance schemes. A number of conditions were imposed on the private insurance companies (7). The reform has succeeded in reducing the proportion of the population without insurance to nine per cent (8), and it has slowed down the hike in costs (7).
The largest health reform since 1965 may soon be history. What will this entail? For those 20 million people who risk losing their health insurance, it is disastrous. In public health terms, other issues play a larger role. After all, the fact that infant mortality in the USA is more than twice the level in Norway cannot be blamed on the health services alone. This must also be ascribed to the huge – and increasing – social inequalities. Inequality has grown under Obama, and Trump’s unshakeable faith in the self-regulatory abilities of the free market indicates that if a change will occur in the time to come, it will be for the worse. The United States’ definition of freedom has created many losers. There is no reason to copy it in this country – and certainly not in terms of health policy.