The Inevitability of Universal Health Care

Why It’s Not Crazy to Think That Trump Could Champion Universal Health Care

By Bill Adams / San Diego Free Press

Universal health care in the U.S. is inevitable. It’s inevitable as long as this country remains among the league of economically developed countries. This inevitability stems from the answer to the fundamental moral question: Do all persons, regardless of wealth, deserve medical treatment? This question is essentially a rhetorical question.

The only acceptable answer in a modern civilized country is “yes.” Yet, the barbaric U.S. health care system tolerates the death of thousands of people per year attributable to lack of health coverage.

Even after the enactment of the Patient Protection and Affordable Care Act (“ACA” aka “ObamaCare”) in 2010, millions remain uninsured or under-insured leading to fatal delay or avoidance in obtaining treatment for treatable and curable illnesses.

The U.S. lags all countries that provide universal health care in every major measurement of health and curing illnesses. Ironically, the U.S. consumer who can afford health insurance receives no benefit for this bloodletting. U.S. health care is the World’s most costly but provides only average medical results – even for those who can afford it.

This fundamental moral question has prompted every single rich country, except the U.S., to adopt a universal health care system. In all such countries, even where the adoption of universal health care was initially controversial, it’s now extremely popular.

In contrast, the U.S.’s non-system is subject of derision and ridicule in the developed world. In health care reform debates in other developed countries, those who seek to stifle criticism or reform point to the U.S. system. The current evasion of these basic truths in the U.S. is not sustainable, even though U.S. insurance companies and medical providers – who have profited from the selective and exorbitantly expensive provision of medical treatment – spend millions to fight against universal care. The only real questions are: When will the U.S. finally fully adopt universal health care, in what form will it happen, and how many more Americans must die before it happens?

The other fundamental fact is that universal health care cannot exist without either a universal mandate to buy in or a universal mandate to provide it free of charge. Thus, all Republican “repeal or replace” bills are doomed to failure and infamy unless they reverse direction and lead the charge to universal health care with something that provides medical care that is cheaper and better than ObamaCare. However, the current trajectory of Republican proposals defy health care economics and thus are doomed to failure.

A Conservative Cause?

First, the reality of universal health care systems in other developed countries is very different than what has been portrayed in conservative media.

Conservatives invariably portray universal health care as “socialized” medicine – exploiting the country’s obsessive fear of communism and our irrational belief that all things non-profit are inferior. Additionally, critics cherry-pick data or provide anecdotes of dysfunction in universal health care in these countries. Taken as a whole, the portrayal is grossly inaccurate.

Moreover, universal health care systems come in a variety of forms, some of which increase competition between private insurers and medical professionals, and increase patient choice.

In his excellent book, The Healing of America, T.R. Reid describes four basic models of health care systems: the Bismark model, the Beveridge model, the National Health Insurance model, and the Out-of-Pocket model. Countries without universal health care employ the last model – including the U.S (except for military personnel and veterans, seniors over 65, and those who qualify for Medicaid.) The other three systems each form the basis for universal health care systems in other developed countries.

For example, the Beveridge model is used in the U.K. Most hospitals and clinics are owned by the government. Doctors and other personnel are employed by the government. Medical treatment is free.

The National Health Insurance model is employed in Canada. Health care is paid for by the government but most of the doctors, nurses, and other personnel and facilities are private.

The Bismark model is used in Germany, Switzerland, Japan, and some other countries. Health care providers and insurers are both private. However, the insurers are non-profits. Health care is paid for with a combination of payroll deductions, employer matching, co-pays, and government payments. Health care is mandated for all citizens.

Reid notes that the Bismark model would be the model most familiar to Americans.

Particularly instructive is what happened in Taiwan in the 1990s, also described in Reid’s book. There, the conservative president, in a political master-stroke, usurped the drive toward universal health care from the liberals. He hired a renowned health care economist (William Hsiao) to design the system. He rushed to implement the new system, against advice, before the next presidential election. Nevertheless, it worked and he was reelected. Reid states:

“Almost overnight, some 11 million Taiwanese who had no medical insurance suddenly had access to doctors and hospitals . . . This created a flood of new demand for medical services. The market responded with a flood of new supply: Clinics, hospitals, dentists, optometrists, labs, hostels, and acupuncture centers sprang up everywhere. . . ‘And that has meant a lot of competition, lots of access for the people, and low prices.’ [quoting Hsiao] The government insurance allows patients free choice of any hospital, clinic, or doctor, so providers end up competing furiously for customers. Many clinics offer free ambulance service to bring the patient to the examining room. . . “

In the U.S., with its obsessive drive to privatize and infuse the free market in all sectors, Taiwan’s health care system fits right in. It’s not surprising then that Romney implemented a similar form of universal health care as governor of Massachusetts. The Massachusetts system became a model for President Obama’s health care reform bill. Obama wanted to avoid the opposition received by the Clintons’ more ambitious plan that failed in 1994.

This is not to say the more socialized systems, like the U.K.’s system, don’t provide great health care. In many ways, they are superior. Beveridge and National Health Insurance models have proved the most effective at suppressing health care costs and in providing preventative care.

But there are powerful for-profit entities – from insurance companies to pharmaceutical companies to doctors – who profit tremendously from the current U.S. system and vigorously oppose change. The Bismark model would be more consistent with conservative ideology and therefore receive more bipartisan support. Like Taiwan, it’s not hard to put a conservative spin on universal health care since many of world’s universal health care systems actually provide more patient choice and have more competition.

However, all such systems either provide health care as a public service or mandate health care insurance or utilize a combination of the two. The more privatized and market-based systems utilize a health insurance mandate. In the U.S., Republican railing against the insurance mandate always seemed an awkward and inconsistent complaint. Conservatives advocate many types of mandates: from car insurance to neighborhood covenants. Here again, opportunity controlled ideology. The health insurance mandate was a linchpin for the success of “Obamacare” and thus became a target of opportunity.

Trump’s Unique Position

Contrary to outward appearances, Trump may be the perfect person to lead the U.S. to a true full-fledged form of universal health care. Trump was elected through a potent cocktail of dissatisfaction and diminishing economic prospects by the working class and middle class.

The significant number of Bernie Sanders to Donald Trump cross-over votes demonstrated the weakness of political ideology, and the strength of dissatisfaction with the perceived establishment, in Trump’s election.

Trump’s embrace of conservative ideology appears more opportunistic than heartfelt. His record reveals that he is more concerned with personal success than the path to get there. His ideology will flex to his bottom-line. His past statements on various political issues were often cited by more ideologically pure Republicans as proof he should be rejected as the party’s nomination for President.

During the election, Trump’s tactics were uniquely suited to take advantage of voter dissatisfaction. His pugilistic personality and willingness to assert simple solutions for complex problems played well for many voters. They perceived a strong and decisive leader who validated their beliefs. Whether fearless or reckless, he was always on offense – always the aggressor – never bound by fact or truth.

However, while style-over-substance may work in an election, governance requires fact-based solutions to produce real and positive results. During his young presidency, Trump has focused on fulfilling his campaign promises, which were based on assumptions and claims contradicted by facts, experts, and scholarship. This strategy may temporarily satisfy his base but like a sugary snack, that energy burst will soon run out unless replaced with real sustenance.

Real facts, science, expertise, scholarship, and discipline are required to give a strategy a high probability for success. So far, there has been no evidence of a coherent fact-based policy initiative coming from this President.

Universal health care is a unique opportunity for Trump to both satisfy a campaign promise and to deliver substantive fact-based change. At first glance, this “opportunity” seems implausible, even ludicrous. Republicans have been the staunchest opponents of universal health care. Their opposition has been based both on ideological grounds and on their ties to the health care industry entities which profit from the current dysfunction.

However, Trump is more populist demagogue than ideological Republican. The Right is already fretting about the possibility Trump will push for universal health care, possibly even a single-payer version. They cite various comments he made before, during, and after the election. With his combativeness and populism, together with some crossing of political partisan lines, he may be the only person capable of gaining support for universal health care across party lines.

By focusing on competition, costs, and patient choice, Trump can spin a universal health care plan as a conservative plan, thereby securing the support of his base. As for getting Congressional support, a chance to expand health care to all would be too tempting for Democrats to reject. Republicans likely would be split among purists who would oppose it and pragmatists compelled by the chance to claim the victory of “repeal and replace” and the opportunity to infuse the bill with market-based elements. The fear of the wrath of Trump and his supporters might also convince some.

To be sure, gaining Congressional support would be the most uncertain part of such a strategy but other options for “repeal and replace” seem even less likely to pass.

Additionally, Trump may be the only person capable of taking on insurance, pharmaceutical, and medical special interests who would oppose universal health care. He has already taken the first step – calling out the Freedom Caucus congressional conservatives for blame in the failure of repealing Obamacare. His popularity appears to exceed the popularity of ideological conservatives among Republican and conservative-leaning independent voters.

While he is currently surrounded by people to whom such a cause would be anathema, for Trump personally, there seems to be little benefit to opposing universal health care and much to gain by supporting it as a “repeal and replace” bill. Perhaps his daughter Ivanka and son in law Jared Kushner can guide him to this cause based on the benefits it would have for him as well as the nation.

Many believe that our President’s actions will only be guided by one question: What’s in it for Trump? That’s the beauty of this strategy for him. He will deliver on his campaign promise of “repeal and replace” by securing more Democratic cross-over votes than Republican opposition votes; he will have a factual basis for claiming one-upmanship on Obama; and he will significantly confuse and mitigate media criticism (reference the popularity of his Tomahawk missile response to the Assad Syrian chemical attack).

He will partially placate the masses while he loots the nation’s future through tax cuts for the wealthy, destruction of the environment and climate, wasteful expenditures, and ill-advised military excursions. He will secure a legacy of accomplishing at least one substantive constructive reform. Universal health care may be both his boldest and his safest path to claim “success.” Even from a purely Machiavellian standpoint, it makes sense for Trump to push for universal health care.

Bill Adams is the founder and chief editor of UrbDeZine. He is also a partner in the San Diego law firm of Norton, Moore, & Adams, LLP. He has been involved with land use and urban renewal for nearly 25 years, both as a professional and as a personal passion. He currently sits on the Boards of San Diego Historic Streetcars, The San Diego Architectural Foundation, The Food and Beverage Association of San Diego County, andThe Gaslamp Quarter Association Land Use Planning Committee.