The United States is about to embark on a great challenge: how to modify the current system of providing health care coverage for its citizens. However, the fundamental underlying question remains unanswered and was rarely mentioned during the past 8 years—Is health care coverage a basic right or a privilege (regardless of how that coverage is provided or who provides it)? Until that question is debated and answered, it may not be possible to reach consensus on the ultimate goal of further health care reform. Without agreeing to the goal, measuring success will be nearly impossible.
The reforms resulting from the Affordable Care Act (ACA) over the past 6 years have led to increases in health care coverage. There is broad consensus that an estimated 20 million to 22 million individuals have obtained health care insurance since 20101- 4 primarily through the expansion of Medicaid, coverage through parents’ policies for young adults until age 26 years, and the health care exchanges. But that leaves more than 25 million US residents without health insurance.5 Is the United States a just and fair society if so many individuals lack health care coverage? The United States guarantees all citizens an education, access to fire and police services, a national postal service, protection by the military, a national park system, and many other federal- and state-funded services. But the country has not yet committed to ensuring that all of its citizens have health care coverage.
The months and years ahead are filled with uncertainty regarding how the US health care system will evolve. For example, will block granting Medicaid lead to a 2-tiered health care system and reduced access, or will it improve quality and reduce the increase in health care costs? If health savings accounts and tax credits replace the individual mandate, will individuals purchase health insurance? Will selling health insurance across state lines truly increase competition and reduce cost, or will it adversely affect the right of states to decide what represents adequate care for their citizens, lead to fewer health care networks with less competition rather than more, and create confusion for individuals who will not understand how such an insurance plan works in their state? Will a pool of dollars to ensure coverage of those with preexisting medical conditions be sufficient, or will these individuals once again be “uninsurable”? Will the various changes being discussed destabilize the commercial insurance market, leading to higher costs and less coverage particularly for those with preexisting health care conditions? Will these reforms solve the problem of increasingly oppressive cost of care for the working and middle classes and small businesses?
The ACA needs to be modified, even though it has accomplished a great deal, principally by expanding the number of newly insured individuals. However, much remains to be accomplished, including how to ensure high-quality, affordable health insurance for all residents and how to control the continual increases in annual health care spending, now exceeding $3 trillion. Whether the proposals currently being discussed will help the United States reach these goals is uncertain, and as with the ACA, measuring outcomes will be important. Sorting out the most effective way to provide health care coverage in the United States is a work in progress and will require careful assessment and likely repeated changes. If the goals of further health care reform are clear and are measured but are not reached, then it will be necessary to return to previous discussions that have included a public option, a single-payer system, lowering the eligibility for Medicare, or further privatization of the health care system.
I hope that all physicians, including those who are members of Congress, other health care professionals, and professional societies would speak with a single voice and say that health care is a basic right for every person, and not a privilege to be available and affordable only for a majority. The solution for how to achieve health care coverage for all may be uniquely American, but it is an exceedingly important and worthy goal, emblematic of a fair and just society.
Corresponding Author: Howard Bauchner, MD, Editor in Chief, JAMA, 330 N Wabash Ave, Chicago, IL 60611 (firstname.lastname@example.org).
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Bauchner H. Health Care in the United States: A Right or a Privilege. JAMA. 2017;317(1):29. doi:10.1001/jama.2016.19687