E.We all know that the United States is the only high-income country without universal health care. By the canonical narrative, this is the inevitable result of American exceptionalism, the different values, cultures, and institutions of America.
it’s not. The push for universal coverage is as strong in the United States as it is in other countries.
In fact, the United States enacted the world’s first national compulsory health insurance law.
1798.
No, it’s not a typo. It’s not just esoteric historical trivia either.
The dynamics behind this early federal health insurance mandate speak volumes about a problem America has tried and failed to solve for centuries: how to provide access to essential health care, regardless of resources.
The existence of this unwritten social contract may be hard to believe in countries that have not yet enacted universal health care, or in societies that insist on self-improvement. But the record is clear. Our country has always tried to provide necessary medical care to those who are sick and unable to care for themselves.
The time has finally come to fulfill this promise. Recognizing that we have always strived and will continue to strive to provide access to health care for those who are ill and unable to seek care on their own, the only solution is to formally state that commitment in advance with insurance coverage.
Alexander Hamilton articulated this argument over two centuries ago. He called on the new parliament to create a tax-funded compulsory health insurance program for merchant seafarers. It was eerily similar to Obamacare in the 21st century. It is a combination of mandatory insurance and fines for non-compliance. In the 18th-century version, each time a U.S. ship returned from a foreign port, each shipowner at sea had to deduct a tax of 20 cents a month per sailor from the crew’s wages and pay it to a customs officer, who would transfer this money to the federal government. He was fined $100 for shipowners found to have evaded taxes.
Rationale for duty: Seafarers come from all over the country, but when they fall ill, the burden is concentrated on local port communities and charitable hospitals that provide care for patients without families. The Solution: A law of 1798 required seafarers to advance funds to be collected by the government and used “for the temporary relief and maintenance of sick and disabled seafarers in hospitals and other suitable institutions.” As the then Secretary of the Treasury, Alexander Hamilton, explained in a 1792 letter to Congress urging the adoption of the policy, the need stems from “the tendency of mankind to protect the very poor classes of the community from want and misery.”
In the 20th and 21st centuries, this very same “tendency”—the human urge to intervene when individuals are ill and lack the resources to care for themselves—has been the driving force behind our long history of patchwork health policies that have so far failed to fully deliver on our moral promises.
The background is the enactment of Medicare and Medicaid in the 1960s to provide health insurance to the elderly and the poor.
And it is behind many subsequent policy increments that have since extended coverage to people with specific diseases such as breast cancer, tuberculosis, end-stage renal disease, HIV/AIDS, Lou Gehrig’s disease, sickle cell anemia, and (most recently) the novel coronavirus. Or for people in specific situations, such as pregnant women, prisoners, or the disabled. In enacting the 1972 policy patch that extended Medicare coverage to the long-term disabled, President Nixon declared that the policy “reaffirms and strengthens America’s traditional commitment to helping people who are unable to help themselves through no fault of their own.”
Even with the slightest knowledge of the state of U.S. health care policy, it is clear that these “traditional efforts” have not been entirely successful.About 1 in 10 Americans are under the age of 65 remain uninsured. Those who are fortunate enough to have insurance are at constant risk of losing their insurance if they lose their jobs, give birth, get older, get healthier, get richer, or move. Even if they were able to maintain their insurance, they still face the risk of huge medical bills for ‘insured’ care. However, these issues represent a breach of our acknowledgment obligations, not an absence of obligations.
There is only one way to satisfy our innate and inevitable social instinct to help those who are sick and lack the resources to care for themselves.
Automatic, Basic, Universal Compensation.
This instinct and solution is recognized all over the world. In the mid-twentieth century, the Austrian economist FA Hayek, famous for his free marketism, denounced the newly formed British National Health Service while at the same time accepting the Hamiltonian rationale for compulsory health insurance. Switzerland likewise invoked what it called “the recognized duty of citizens to provide for the extreme needs of illness” when it created mandatory universal health care in 1996.
Over the past few decades, this rationale for universal health care has been embraced by American leaders beyond political positions. Massachusetts Republican Governor Mitt Romney mandated universal health care in Massachusetts several years before the Affordable Care Act of 2010. He argued that uninsured individuals who become ill will eventually receive medical care but will not pay for most of it, so they should be required to have insurance to pay for treatment in advance, much like 18th-century sailors did. Supreme Court Justice Ruth Bader Ginsburg similarly cited “the embedded societal norm of providing care when it is most needed, regardless of a patient’s ability to pay.” 2012 opinion Supports the constitutionality of the Obama administration’s health insurance mandate.
The intuition was right, but the implementation was wrong. As we all know by now, the United States she mandated universal health care in 2010 and has yet to achieve it. 30 million Americans remain uninsured. If you call it universal, it’s not.
The only solution is to automatically provide compensation funded by taxes on earned income. So did the sailors of the 18th century. It can be very basic. Our social norm is to provide essential care, not luxury services. But unless we do, our urge to meet our social obligations will be doomed to repeat the never-ending cycle of incomplete half-measures and inadequate patching of health policy, the history of our health care spanning more than half a century.
This is not a liberal or conservative argument. It’s just common sense.
Liran Einuff is an economics professor at Stanford University. Amy Finkelstein, professor of economics at the Massachusetts Institute of Technology (MIT). This essay is based on their new bookWe’ve got you covered: Rebooting America’s healthcare”
