Despite the 2010 passage by the most recent Democratic Administration of a radical upheaval of the existing health-care system, the issue of reform is back at the forefront of debate this Democratic primary season. What was once “extreme” is now seen as gravely insufficient. I moved here from Canada in 2016, thankful for the fact that I would be eligible for Obamacare and couldn’t be turned away because of my pre-existing condition, having received a kidney transplant over a decade ago. But I’ve now come to the same conclusion as many on the left: It is still, for all intents and purposes, not genuinely feasible to be sick on Obamacare.
This year, as an American resident, my total yearly premiums for 2019 will come out to around $5,545. (This is also more than $1,000 above the yearly premiums I paid in 2016, which came out to around $4,500.) Like many other people with disabilities or chronic health conditions, I frequently make contact with the health system; I pay $40 to see a specialist and $150 each for what, to me, are quite routine and necessary tests, like MRIs. This brings my yearly total spent on health care to probably just shy of $7,000.
According to DC Health Link, the District’s exchange, I’d have to make a yearly gross income of around $37,000 or less to qualify for any subsidies. I would then be eligible only for a silver plan, one with high deductibles that could bring my total spending to as high as around $11,000, more than the total I pay for my current platinum PPO plan. Unfortunately for me, existing subsidies take into account only my age and not my health status. (That is to say, these subsidies do not take into account that my health needs, and therefore costs, are more akin to those of a 60-year-old than those of a 30-year-old.) The cheapest subsidized silver HMO plan would also not cover my current nephrologist or my GP. (Despite right-wing fear-mongering to the contrary, the Canadian system allowed me to see whichever doctor I chose.)
On December 22, 2017, Donald Trump and the Republican Congress passed the Tax Cuts and Jobs Act. This repeals the Obamacare tax on those who opt out of the system. This led the CBO to estimate that around 13 million individuals would therefore be leaving the exchanges. Not surprisingly, I recently received an e-mail warning of premium increases for 2020 in the District of Columbia of as high as 15.6 percent. Although it’s been difficult for Republicans to get rid of coverage for those with preexisting conditions, with a system so complex, it’s not particularly hard to pick apart the program’s less popular elements and, in doing so, still punish those who rely on the system the most.
According to a Gallup poll conducted in 2018, around 30 percent of patients failed to obtain the care they needed due to high out-of-pocket costs. And this cost burden is, of course, higher when you have a chronic disease. For example, in 2015, whereas only 2 percent of all enrollees spent more than $5,000 on out-of-pocket spending, 4 percent of those with cancer did. This number rose to 10 percent for those suffering from lymphatic or colorectal cancers. And for mental health care, it is those in the direst need who suffer the greatest cost burden. In 2015, 16 percent of those seeking suicide prevention treatment paid more than $5,000 a year, whereas 62 percent paid more than $2,000. The percentage of patients who defer treatment due to cost has not improved over the past 13 years, despite the increased number of people covered by insurance.
The existence in the U.S. system of insurance churning—insurers replacing clients’ coverage packages without letting them know—and the fact of patients changing insurance when they change jobs disrupts continuity of care and is particularly problematic for patients with more complex needs. A recent study by the American Journal of Public Health found that although the ACA had vastly improved access to health care for those with disabilities, substantial disparities remain. Access to mental health care remains an issue, and those with disabilities were more likely to have delayed or forgone care.
Luckily for me, end stage renal failure is one of only two medical conditions covered by Medicare regardless of age. But even then the system remains convoluted, with obvious holes. Medicare becomes effective only once someone with ESRD has started dialysis. Medicare will cover expenses for the first three years after a transplant, at which point patients must obtain private insurance. This has resulted in many people losing viable organs because they could not afford private insurance and, therefore, could longer afford their immunosuppressants. Finally, chronic illness often coexists with mental health needs. Despite legislation mandating parity for mental health care, insurance companies have continued to deny such care on the basis of a supposed lack of “medical necessity.”
In Canada, despite more than a decade as a transplant patient, I had never paid for any medical expenses (beyond medications) related to my condition: no premiums, no copays, no deductibles. I’d never had to choose among a plethora of confusing, convoluted plans, I simply renewed my medical insurance card every four to eight years, which I showed upon arrival at the doctor’s office (no credit cards involved). And although wait times in Canada are reportedly among the highest in the OECD, as someone with a chronic disease, I found that I was often treated for both my kidney disease and coexisting problems quite quickly. Apparently about 70 percent of Canadians with chronic health conditions agree that they often or always have the treatments they need. But perhaps most importantly, patients are freed of the psychological stress of intense worry over unpaid bills, as American cancer survivors were shown to suffer from in a recent study. And despite all the hysteria about higher taxes from single payer, a few quick online tax calculators revealed that, at my income level, I’d pay almost the exact same income tax in both places.
This is not to say there are not important shortcomings in the Canadian system. For example, supplementary private insurance is still necessary to cover things like dental care and vision, among a few others. In most of Canada, there is no public pharmacare plan. Instead, there is a patchwork of mostly private drug plans, dependent on employment status (akin to a micro-cosm of the American system). This has left some Canadians without insurance and others with inadequate coverage.
But despite the efforts of conservative parties in the United Kingdom and Canada to starve and undermine the system, it is also more easily subject to democratic accountability than a convoluted, piecemeal one like the United States’s. After years of austerity, Québec’s recently elected conservative CAQ government was forced to lay out promised increases to health spending to secure its win. Likewise, Canadian Conservative Party leader Andrew Scheer has promised a yearly increase in federal health transfers by at least 3 percent should he be elected this October. Unsurprisingly, filling in the gap in medication insurance through a national pharmacare program has also become a hot topic in Canada’s 2019 election campaign and seems likely to be addressed in the coming years. The Canadian health-care system has become somewhat of an immovable object, despite numerous attacks on it. (To some degree, the same could probably be said of the ACA’s provision to protect those with pre-existing conditions.) It may, therefore, be harder than some Americans fear for the Republicans to take apart a similar system once in place.
Many pundits critical of Medicare for All and its political viability have pointed out that Vice President Biden’s buffed up ACA is actually a lot more radical than it may appear. Admittedly, many of his campaign’s suggested improvements would certainly help. For example, Biden’s plan would cap premiums at 8.5 percent of income: I currently pay around 11 percent. This would bring my premiums back to something resembling those when I first arrived (only three years ago, mind you). The public option would also be available to anyone, even those with private insurance through work. The plan would attempt to reduce costs by negotiating for lower prices from health-care providers and drug manufacturers, therefore supposedly offering lower premiums, and would pay for higher and more expansive subsidies through a small increase in capital gains tax for the very rich.
But those looking to countries like the Netherlands, Switzerland, and Germany as examples should take heed. In the Netherlands, private insurance programs are so heavily regulated they barely resemble private insurance. Meanwhile, increased competition has done little in the way of improving the quality of care, and recent polls have shown a desire to move toward a system more akin to single payer. In Germany, where citizens are covered by a mixture of public and private “sickness funds,” the number of people who choose to opt out of public insurance has dropped precipitously since 2000 when the government decided that those who opted out could not opt back in; too many Germans were choosing lower private premiums while young, switching back to the public when they grew old. And although Switzerland may rely quite heavily on private insurance, unlike in the United States, it is not tied to place of work and out-of-pocket costs are high. Yet these countries are much more homogenous and do not face the issues of extreme inequality and glaring barriers to access that the United States does, leading experts to question their applicability. In other words, it would appear to be in spite of and not because of private insurance in these systems that they have achieved successful outcomes.
Biden promises that, under his plan, 97 percent of Americans would be covered. Beyond wondering what the other 3 percent, 9.8 million people, are supposed to do, the constant emphasis only on near universality of coverage neglects the fact that a health-care system should also be based on other principles, like redistribution from healthy to sick, and from rich to poor; it should mean fairness in access based on need alone. The Canada Health Act, passed into law in 1984, states that the purpose of the Canadian system should be “to protect, promote, and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access without financial or other barriers.” In 1961, Tommy Douglas, father of Canadian health care, became leader of the national New Democratic Party, while his single payer bill was being implemented in Saskatchewan. He lost his seat in the 1962 election. The provincial branch of his party lost in 1964, likely due in part to the intensive scare campaign against Medicare carried out by Canadian doctors and other health-care interests. Ironically, however, the governments that replaced them could only do so by promising to maintain Medicare. Meanwhile, single payer health care at the national level had, by that point, become inevitable.
So for those of us whose lives rely upon the provision of health care, exhausted not just by poor health but by a poor system, it is hard not to feel that a more truly universal, redistributive, and humane system in the United States could one day be a political hill worth fighting, and perhaps even dying, on.