Falling Further Behind on Health
In this post, Emily K. Brunson and Jessica Mulligan weigh in on the current debates over health care in the United States, highlighting the failures of the US health system to provide equitable access to health care. For more information on how you can make your voice heard in the health care debate visit https://5calls.org/.
This is the first entry in our new series “De-Provincializing Development,” which seeks to cast a critical eye on US progress towards the new UN goals. It examines SDG #3: Healthy Lives and Wellbeing.
Source: Flickr.
Is the United States developed? When it comes to health, the answer may be no.
In 2015, 150 nations agreed to the United Nations Sustainable Development Goals (SDGs). These goals provide a benchmark by which all countries can measure themselves. The sustainable development goal for health (SDG 3)—“To ensure healthy lives and promote well-being for all ages”—comprises thirteen targets, including reducing neonatal mortality, strengthening the prevention and treatment of substance abuse, and ending the epidemics of AIDS, tuberculosis, and malaria. While the United States actively supports other nations’ efforts to promote health, domestically it is far from meeting some of the targets and, especially compared to other developed nations, far from ensuring health for all.
Under the Trump administration, work on the SDGs appears to have stalled. Web sites for official US reporting on SDG progress have not been updated in some time. The United States is not among the eighty-two countries that have conducted voluntary national reviews of their progress on the SDGs and published them on the UN website. And withdrawal from the Paris Climate Accord—which moved the US farther away from achieving multiple SDGs relating to climate, sustainability, and the environment—signals the direction the current administration is moving: more isolation, less interdependency, and an aversion to “sustainability.” Regarding health, in particular, recent health care legislation passed by the House and other legislation proposed by the Senate actively moves the country in the opposite direction of SDG 3.
“While the United States actively supports other nations’ efforts to promote health, domestically it is far from meeting some of the targets and, especially compared to other developed nations, far from ensuring health for all.”
Most critically, the United States is the only developed nation that relies heavily on a non-universal, market-driven, employment-based insurance system. This has significant implications for health care equity. The life expectancy of the poorest Americans, for example, is ten to fifteen years less than the life expectancy of the wealthiest Americans. Disparities in life expectancy occur for a variety of reasons, including that those living in poverty are at greater risk of accidents, violence, and chronic conditions like diabetes and infectious diseases. But the health care system is also to blame. The poor often lack access to treatment for these conditions due to its high cost, the location of services, and racial and ethnic biases that can result in low-quality care.
Source: Flickr.
Among those in the middle (neither poor nor rich), the costs of premiums, deductibles, and copays have priced many individuals and families out of care. This situation, termed underinsurance, is directly associated with worsening health, including increased mortality and an increase in depressive symptoms. Only the truly rich fare well under the current system, where large amounts of money can buy increasingly exclusive forms of care, like concierge medical services that provide things like lengthy office visits and unfettered access to specialists.
Over the years, a few policies have been implemented to address equity in the US health care system, including the passage of Medicare and Medicaid in 1965, and more recently the Affordable Care Act (ACA) in 2010. While Medicare and Medicaid were quickly accepted and integrated into the US health care system, the ACA—which, among other things, sought to improve access to care by expanding Medicaid eligibility and mandating that those not eligible for Medicaid purchase private insurance—has produced mixed results and has remained controversial.
In its favor, the ACA has improved rates of insurance coverage: the number of people without insurance in the United States dropped from 48.6 million in 2010 to 28.6 million in 2015. In addition, the ACA improved health care access for women of childbearing age, the old, the mentally ill, those with preexisting conditions, and racial minorities by (1) ensuring equitable access and cost parity for women, older adults, people experiencing mental illness, and people with preexisting conditions; and (2) providing increased funding for community health centers that often serve low-income, minority populations.
At the same time, the ACA has proved insufficient in providing care for all. After a Supreme Court ruling in 2012, multiple states (nineteen as of 2017) opted against expanding Medicaid. Even in states where Medicaid was expanded, access to specialist care was often limited to providers who would accept the lower payments associated with this government program. In addition, the ACA did not reverse—and may have even exacerbated—the trend of increasing cost sharing associated with insurance plans. This left many individuals underinsured: they had health insurance but were not able to afford the costs associated with things like sick visits, treatment for chronic conditions, and even minor injuries. Proponents of the ACA have suggested reforming the law to address these issues. Opponents, including President Trump, have suggested repealing the ACA and replacing it with something else.
“Instead of simply repealing the ACA and replacing it with an even more market-based system, the United States would be better served if the country pushed toward a more equitable health care system. Recommitting to the SDGs and following the example of other countries in offering universal coverage seems like a good place to start.”
At this time it is not entirely clear what this something else will be (although with Republican control of the federal government it seems inevitable that the United States will end up with something else). Current proposals include keeping subsidies to help poor Americans buy health insurance, but with a lower threshold; eliminating funding for programs that promote women’s health, such as Planned Parenthood; cutting Medicaid funding across the board; and allowing states to make changes to Medicaid programs, like requiring drug screening and/or proof of employment to qualify and setting time limits on benefits. Philosophically, these neoliberal measures are meant to discourage “welfare dependency” and promote “personal responsibility.” Practically, however, all of these measures will result in less care for the poor and greater inequality in the health care system. This is the opposite of SDG 3.
Instead of simply repealing the ACA and replacing it with an even more market-based system, the United States would be better served if the country pushed toward a more equitable health care system. Recommitting to the SDGs and following the example of other countries in offering universal coverage seems like a good place to start.
Emily K. Brunson is an assistant professor of anthropology at Texas State University.
Jessica Mulligan is an associate professor of health policy & management at Providence College.
CITE AS
Brunson, Emily K., and Jessica Mulligan. 2017. “Falling Further Behind on Health.” American Anthropologist website, July 11.