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The United States does not have a uniform health system and has no universal healthcare coverage. The health disadvantage of the U.S. relative to other high-income countries is health disparities in health services.

The United States does not have a uniform health system and has no universal healthcare coverage. The health disadvantage of the U.S. relative to other high-income countries is health disparities in health services.

Every election brings with it debates over health care. Amanda Aronczyk, with our Planet Money podcast, noticed that the word Canada keeps coming up again and again in those debates and how the Canadian system would supposedly never work here. As a Canadian living in the U.S., to Amanda, that was confusing. So she went digging.

(SOUNDBITE OF ARCHIVED NPR BROADCAST)

A Reuters survey in August found that the vast majority of Americans, 70%, now support Medicare-for-all. And doctors, many who once vehemently opposed the idea, are increasingly on board. A survey last fall found that physicians favor a single-payer system by a slight margin even though many say their income will suffer under such a system and possibly lower the quality of care. The survey found that physicians favor a single-payer healthcare system (48%) over a multiple-payer system (45%).

But Pipes, director of the conservative think tank and an outspoken critic of government-run healthcare, said instead of looking to the neighbor to the north as a model, Americans should look at the Canadian health system as a warning. When the government is the sole provider of healthcare, you get long wait times, rationed care and higher taxes, she said.

Structuring a workable enrollment process will be important under any expansion. Managing enrollment is easier if the eligibility age is reduced to 62, when many Americans begin to take Social Security benefits. For more extensive changes, and to assist Americans who delay Social Security receipt until after age 62, Social Security offices may need to be enlisted in enrolling newly eligible Medicare beneficiaries. The addition of an automatic notification process for eligible enrollees not already receiving Social Security benefits would be necessary to maintain near-universal enrollment among the eligible population. Public education efforts might be coordinated with the Social Security Administration’s outreach to notify older persons as they approach the Medicare eligibility age, which would help existing as well as new beneficiaries.

The Medicare for All Act would provide health care for all, including visits to providers of primary care, vision, dental, reproductive care, and more, without out-of-pocket expenses and insurance premiums. Prescription drugs would also be covered, and the government would be allowed to negotiate prescription drug prices with pharmaceutical companies. Because coverage would be universal, patients would no longer have to jump through hoops to sort out which providers are covered, as the concept of “in network” would, like in other countries, largely no longer exist.

In short, Medicare for All would revolutionize the U.S. health care system. It would ensure that the estimated 85 million Americans who are uninsured or underinsured could access health care without substantial costs, while other Americans would no longer have to live in fear of losing coverage if they lose their jobs.

Medicare For All would wipe out the insurers and their high executive pay and denial of care. It would also give the federal government—which now foots half of the nation’s health care costs—the power to dictate drug prices to Big Pharma, the fact sheet says. If passed, it would be phased in over four years.

It also “would provide comprehensive health care coverage to all with no out-of-pocket expenses, insurance premiums, deductibles, or co-payments. This includes coverage for primary care, vision, dental, prescription drugs, mental health, substance use disorder, long-term services and supports, reproductive health care, and more,” the fact sheet adds.

The United States is at a health care crossroads. We either move forward toward making health care a basic right for everyone, or fall backward, with coverage and care increasingly out of reach as politicians actively take it away, employers cut back and higher prices make it ever harder to afford.

Making Health Care a Right

The critics miss the point. First, Medicare for All would do nothing to change the provision of health-care; it is only concerned with the financing. The provision of care, the way people fill prescriptions or receive care from doctors and hospitals, would not change at all. Why would it? Already nearly half of healthcare is financed by the government without disrupting relationships between patients and caregivers. In existing Medicare, people choose a physician and see them as needed, physicians treat patients as they believe appropriate, and Medicare is billed at established rates. Medicare for All would change nothing because it would continue to operate under the same insurance model as existing Medicare. Everyone would choose doctors just as the elderly and disabled do under Medicare now. Doctors and hospitals would treat patients according to their medical needs and would be paid according to a price list set as under Medicare now. People would fill prescriptions and buy medical devices paid for by Medicare, as happens now.

The only change for people currently receiving Medicare is that Medicare for All would provide comprehensive benefits without costsharing, eliminating the need for any private Medigap coverage. And it would be tax-funded, eliminating the premiums now paid for Part B (physician services).

The U.S. national economy is composed of a vast collection of local and regional economies, where state and local policies play a significant role. Collectively, state and local governments outspend Washington on direct goods and services, employ more workers than the domestic manufacturing sector, and are responsible for about 15 percent of national GDP.

States and cities supply nearly 80 percent of the $441 billion spent nationally on transportation and water infrastructure, according to the Congressional Budget Office’s most recent data. These investments help fuel the economy directly by creating jobs in sectors such as construction, experts say, and are also essential for improving long-term economic efficiency and international competitiveness. (For example, less congestion lowers business costs.) The 2019 Global Competitiveness Report from the World Economic Forum (WEF) ranked the United States second overall in economic competitiveness, but thirteenth in quality of infrastructure. The American Society of Civil Engineers gave the United States a D+ in its 2017 Infrastructure Report Card—the same grade it gave in 2013.

Most states provide less support per student for elementary and secondary schools — in some cases, much less — than before the Great Recession, our survey of state budget documents over the last three months finds. Worse, some states are still cutting eight years after the recession took hold. Our country’s future depends crucially on the quality of its schools, yet rather than raising K-12 funding to support proven reforms such as hiring and retaining excellent teachers, reducing class sizes, and expanding access to high-quality early education, many states have headed in the opposite direction. These cuts weaken schools’ capacity to develop the intelligence and creativity of the next generation of workers and entrepreneurs.

Our survey, the most up-to-date data available on state and local funding for schools, indicates that, after adjusting for inflation:

Schuler points to legislation in the state that would reduce the carbon load in gasoline sold there. The cost to state coffers would amount to $385,900 annually during the first seven years of the program, which is expected to reduce greenhouse gas emissions attributable to cars and trucks by about 10% during that time.

Wildfires that have charred millions of acres in California, Washington and Oregon in recent weeks illustrate the need for climate action to continue despite the pandemic, Schuler says.

By the numbers: The biosciences employed 1.87 million people across 101,000 U.S. businesses with a $2.6 trillion total impact on the U.S. economy in 2018, says Driving the Bioscience Economy Forward During the COVID-19 Pandemic: Best Practices in State and Regional Economic Development Initiatives.

Workers in the sector averaged more than $107,000—nearly twice the national average. And there are more of them, with the bioscience employment base growing by 7.2% since 2018, more than twice the rate for the overall private sector.

The recent economic downturn has had a significant impact on the bioscience industry. Venture capital investment in the industry is down more than 50% from the previous year. Of the publicly traded bioscience companies, over 90% have experienced significant losses in their market capitalization. Smaller bioscience companies are more acutely affected, with many companies trading below their cash value and with less than a year's worth of operating capital remaining in their coffers. Due to pressure from investors looking for quick returns, some companies are abandoning research on new products and technologies and only focusing on products that are further along in the development phase. While the economic climate has been difficult for bioscience companies, it has also had a significant impact on state budgets, causing many states to cut programs and reassess economic priorities. The biosciences continue to be a high growth, high value industry for many states. Almost every state in the country is actively engaged in building bioscience industry infrastructure. State sponsored programs to encourage investment and help bioscience companies leverage existing resources can be instrumental in helping these innovative companies survive this economic cycle. This report chronicles several types of state programs that have been very helpful in helping to form and sustain bioscience industry development. Until a decade ago, the United States was the undisputed leader in bioscience industry development. However, a variety of factors such as low cost labor, speed of information dissemination, and available risk capital, has rapidly increased global competition for the industry. Europe and Asia, for example, are actively promoting opportunities for bioscience companies. State governments continue to understand this new dynamic of increased competition for developing the biosciences and are actively working to develop and promote to grow the industry within their states. According to the study "Technology, Talent and Capital: State Bioscience Initiatives 2008¹," the bioscience industry is a growing and vibrant sector of the U.S. economy, with more than 42,000 businesses employing 1.3 million people in all 50 states, Puerto Rico and the District of Columbia. Direct and indirect employment in the biosciences sector accounts for 7.5 million jobs.

States’ and localities’ influence over health care, as well as many other social and economic, behavioral, and environmental factors that shape health, is most apparent in their budget decisions.[16] Health is one of the largest categories of state and local spending, making up more than a quarter of state and local expenditures.[17] It includes health coverage programs like Medicaid and the Children’s Health Insurance Program (CHIP), as well as spending on behavioral health services for people with mental health and substance use disorders, and public health departments that lead disease prevention and health promotion efforts such as vaccination programs, food safety, and disaster preparedness and response. These public investments directly affect residents’ health, and they play a critical role in determining health outcomes.[18]

While less obvious, aspects of nearly every other category of state and local expenditures can also affect health:

Currently, much infrastructure spending is funded and directed by states

Total public spending on transportation and water infrastructure was $416 billion in 2014. Of that total, just 23 percent came from the federal government, with the vast majority—77 percent—coming from state and local governments (CBO 2015).

Properly addressing the nation’s aging infrastructure requires action not only at the federal level, but also at the state and local levels, where most infrastructure spending is carried out. This document examines the key role that state and local governments play in providing and maintaining the nation’s transportation and water infrastructure.

FEDERAL VERSUS STATE AND LOCAL INFRASTRUCTURE SPENDING

State investment in transportation, public buildings, water treatment systems, and other forms of vital infrastructure is key to creating good jobs and promoting full economic recovery. States should reject the flawed economic growth strategy of cutting taxes and offering corporate giveaways, and instead identify and make investments in infrastructure that provide the foundation for a strong economy. It’s a good time for states to make those investments.

The condition of roads, bridges, schools, water treatment plants, and other physical assets greatly influences the economy’s ability to function and grow. Commerce requires well-maintained roads, railroads, airports, and ports so that manufacturers can obtain raw materials and parts and deliver finished products to consumers. Growing communities rely on well-functioning water and sewer systems. State-of-the art schools free from crowding and safety hazards improve educational opportunities for future workers. Every state needs infrastructure improvements that can pay off economically in private-sector investment and productivity growth.

State and local governments are the stewards of most of the country’s public capital.

They own over 90 percent of non-defense public infrastructure assets, and although the federal government assists in the building and maintenance of these assets, state and local governments pay 75 percent of the cost of maintaining and improving them. (See Figure 2.)

State and local governments across the United States spend roughly half a trillion dollars annually on transportation and water infrastructure, with about one-quarter paid for through grants from the federal government. This spending includes investments in new projects as well as general upkeep and operating costs for roads, bridges, and public transit systems, as well as the development and maintenance of state and locally managed water resources.

Still, experts warn that these commitments will not be enough to keep pace with the growing backlog of needed repairs, or the significant upfront investments required to modernize core public infrastructure systems. In a 2019 report, researchers from the Volcker Alliance, a nonprofit organization focused on public finance issues, estimated that the costs for delayed repairs and maintenance that has accumulated nationally over the past 50 years could reach nearly $1 trillion. That represents about 5% of the nation’s gross domestic product (GDP), but the estimate is likely low. Last year, The American Society of Civil Engineers projected these costs could be double that amount.

The COVID pandemic adds a new sense of urgency to establish a universal health care system in the United States. Our current system is inequitable, does not adequately cover vulnerable groups, is cost prohibitive, and lacks the flexibility to respond to periods of economic and health downturns. During economic declines, our employer-supported insurance system results in millions of Americans losing access to care. While the Affordable Care Act significantly increased Americans’ coverage, it remains expensive and is under constant legal threat, making it an unreliable conduit of care. Relying on Medicaid as a safety net is untenable because, although enrollment has increased, states are making significant Medicaid cuts to balance budgets. During the COVID-19 pandemic, countries with universal health care leveraged their systems to mobilize resources and ensure testing and care for their residents. In addition, research shows that expanding health coverage decreases health disparities and supports vulnerable populations’ access to care. This policy statement advocates for universal health care as adopted by the United Nations General Assembly in October 2019. The statement promotes the overall goal of achieving a system that cares for everyone. It refrains from supporting one particular system, as the substantial topic of payment models deserves singular attention and is beyond the present scope.

Relationship to Existing APHA Policy Statements