Universal Health Care: Debate, Evidence, and Public Opinion

Introduction to the Universal Health Care Debate

Universal health care is a contentious topic for many Americans, particularly since the Affordable Care Act — commonly called "Obamacare" — was signed into law. However, the discussion of some form of national health care legislation predates President Obama's time in office by many years. The debate is nothing new, but there are two distinct sides to the issue, both of which carry significant weight when considering what would be best for the American public and for the health care system they depend on now and in the future.

As far back as 1989, Relman was addressing the issue of universal health insurance in the New England Journal of Medicine. He argued at that time that universal health care was an idea whose time had come, and that something needed to be done to protect the American people from the rising expense of medical care and the lack of treatment that many uninsured people were forced to endure. Those without insurance had few choices and little ability to improve their situations, leaving many reliant on government assistance (Relman, 1989). But was the government system adequate? Could it provide everything that people actually needed in order to survive and thrive in an era when medical care was becoming increasingly expensive? According to Relman (1989), the National Leadership Commission on Health Care had been planning a proposal for universal health insurance by the end of 1988.

At the time of Relman's writing, that proposal had not yet been made public. Other issues had been addressed and other writings had appeared in the health care debate, but the Commission's proposal remained elusive. This troubled Relman (1989), given the lack of health care that so many people were experiencing and the apparent unwillingness of the government to act. Was health care going to become something that only the wealthy could afford? This question was later taken up by Asch et al. (2006) and addressed by Veugelers and Yip (2003). Both studies consider the issue of socioeconomics as it relates to health care access and quality. While they address a similar concern, they are far from identical in their approach or findings.

Socioeconomic and Demographic Disparities in Health Care Quality

Asch et al. (2006) put forth the finding that adults within the United States actually receive only about half of the medical services recommended for their age, condition, health problems, and other relevant factors. This shortfall, however, is not evenly distributed across the population. Some groups face far greater risk than others of being denied care or of simply being unable to access the care they need. Older adults, people living in poverty, those with less education, women, and racial minorities are among the groups that have the most difficulty obtaining proper health care (Asch et al., 2006). Although there are exceptions within each of these groups, they are generally underserved by the medical community. As Asch et al. (2006) examined these populations, it became clear that the numbers affected were substantial, and that many individuals could be classified into more than one at-risk group — making it more difficult to assess precisely how many people were vulnerable to substandard medical care.

Interestingly, Asch et al. (2006) found that having insurance — or lacking it — did not play a statistically significant role in whether a person received high-quality health care. The patient's demographic characteristics were more predictive of the kind of care they received. Women received more preventive care but less acute care than men, while older patients received less care overall than younger ones (Asch et al., 2006). Although these patterns make sense when considered broadly, they remain important to examine in relation to insurance status, particularly because insurance did not appear to be directly linked to the quality of care received in any demographic group. It is worth noting, however, that this finding applied only to patients who had at least minimal access to care and who had seen at least one medical professional in the previous two years.

Would Universal Coverage Reduce Health Inequalities?

Veugelers and Yip (2003), writing in the Journal of Epidemiology and Community Health, studied a related question: whether universal health insurance coverage would reduce the disparities observed in health care quality. Their study concluded that universal health care would give people of lower socioeconomic status greater access to care, allowing them to stand on more equal footing — from a health standpoint — with those who had more financial resources and therefore better access to medical services. However, Veugelers and Yip (2003) also concluded that universal insurance would not, by itself, equalize mortality rates between lower- and higher-income groups. This was largely because uninsured individuals tended to delay seeking care until they were seriously ill, often turning to the emergency room rather than visiting a primary care physician at regular intervals.

This pattern left them at risk for conditions that went untreated for extended periods and prevented them from purchasing medications their doctors had prescribed. With universal access to health care, mortality figures could become more equitable between income groups. Specialist services, however, are widely underused among lower socioeconomic classes, and it remains unclear whether universal coverage would correct that problem. It is possible that specialist care would not be fully covered under such a system, meaning that people with fewer financial resources might still be unable to see specialists — even if their access to hospitals and general practitioners improved.

Taken together, Asch et al. (2006) followed up on what Veugelers and Yip (2003) had examined regarding the relationship between lack of insurance and inadequate medical care. The key difference between the two studies lies in their emphasis: Asch et al. (2006) analyzed the issue through a demographic lens, while Veugelers and Yip (2003) focused more narrowly on economic factors. Their conclusions also diverged. Veugelers and Yip (2003) suggested that providing insurance to lower-income populations would benefit them by enabling more frequent, less urgent medical visits and thereby reducing mortality. Asch et al. (2006), on the other hand, found that insurance status did not account for enough of the disparity between demographic groups to make a significant difference in treatment quality. While this conclusion may seem counterintuitive, both studies employed sound methodology and arrived at findings appropriate to their respective research designs.