We've Got You Covered

1. America's Health Insurance System Is a Broken, Haphazard Mess, Not a System.

America’s health care system is neither healthy, caring, nor a system.

A universal mess. The U.S. healthcare system is not the result of deliberate design but a chaotic accumulation of patches and fixes layered over decades. This piecemeal approach, driven by reactions to specific problems or political pressures, has created a structure that is incoherent, uncoordinated, and inefficient. It fails to provide reliable coverage or financial protection for many Americans.

A history of patches. Since the mid-20th century, U.S. health policy has been characterized by attempts to mend a fundamentally flawed structure rather than rebuilding it. Examples include adding coverage for specific diseases (like ESRD or breast cancer), creating temporary eligibility pathways during disasters, or enacting laws to prevent patient dumping. These efforts, while often well-intentioned, address symptoms rather than the root cause and inevitably leave significant gaps.

Renovation is futile. The long history of inadequate, incremental reforms demonstrates that patching the existing system is a losing battle. Like a dilapidated house with a rotten foundation and shoddy construction, the current structure cannot be salvaged through renovation. The only viable path forward is to tear down the existing "system" and build a new one from the ground up, based on a clear purpose and sensible design principles.

2. The Risk of Being Uninsured or Underinsured Is Pervasive, Even for Those with Coverage.

Right when you fall ill and need insurance most, you can find yourself suddenly, unexpectedly, uninsured.

Coverage is precarious. While much attention focuses on the 30 million Americans uninsured at any given moment, the problem of coverage extends far wider. One in four Americans under 65 will be uninsured at some point over a two-year period. This instability affects both privately and publicly insured individuals, creating constant uncertainty.

Employer-based fragility. Nearly half the population gets insurance through an employer, a historical accident from WWII wage controls. This link means losing a job often means losing insurance, precisely when medical needs might increase. COBRA allows continuation but is prohibitively expensive for most unemployed workers.

• Employer contributions are tax-free, a $300 billion annual subsidy.
• COBRA premiums averaged $12,000/year in 2019.
• Only a tiny fraction of unemployed workers use COBRA.

Public program instability. Public insurance like Medicaid is tied to frequently changing eligibility factors (income, age, health status, location). People cycle in and out of coverage, often losing it when their income rises slightly, they get older, or even if their health improves.

• One in four women on Medicaid during pregnancy lose coverage postpartum.
• Kids can lose coverage by turning 1 or 6, or aging out at 18 (or 26 if in foster care).
• Eligibility rules are complex, vary by state, and require burdensome re-enrollment paperwork.

3. Our History of Patchwork Policies Reveals an Unwritten Social Contract to Care for the Needy.

Fellow creatures could not be allowed to die in the streets.

An enduring impulse. Despite the gaps and failures of the U.S. healthcare system, a deep-seated social norm persists: a commitment to provide essential medical care to those who are desperately ill and unable to afford it. This impulse is not always fulfilled effectively, but it is consistently present in policy responses throughout history.

Responding to crises. This social contract is often triggered by "moral emergencies" – acute, visible crises that evoke compassion and a sense of obligation. Examples include:

• The creation of disease-specific programs (ESRD, ALS, COVID) in response to salient illnesses.
• Laws requiring hospitals to stabilize patients in emergencies (EMTALA), even if follow-up care isn't guaranteed.
• Temporary expansions of coverage during natural or man-made disasters (Hurricane Katrina, 9/11, Flint water crisis).

The deserving poor. The impulse to help is often filtered through a historical lens distinguishing the "deserving" from the "undeserving" poor. Illness has often served as a "tag" for deservingness, leading policies like early hospitals and Medicaid eligibility to focus on groups seen as blameless for their plight (children, elderly, disabled). This moral intuition, while understandable, has led to fragmented and illogical policy outcomes.

4. Society Already Provides Significant Care to the "Uninsured" Through a Fragmented, Inefficient Safety Net.

No one in America is actually uninsured when it comes to their health care.

Implicit insurance exists. While lacking formal insurance, individuals who cannot afford necessary medical care are not left entirely to fend for themselves. They receive a substantial amount of care, often paying only a fraction of the cost, particularly for large bills. This is effectively a form of implicit insurance, albeit one that is unpredictable and burdensome.

A vast, uncoordinated web. This implicit insurance is supported by a complex network of public policies and funding streams, far beyond just emergency rooms.

• Hospitals (especially non-profit and public ones) are legally required to provide some charity care.
• Federally Qualified Health Centers provide free or low-cost primary and preventive care.
• Numerous federal, state, and local programs target specific diseases, populations, or services.

Inefficient and burdensome. This safety net is incredibly inefficient. It involves complex eligibility rules, burdensome application processes, and fragmented funding streams that require clinics to navigate a maze of bureaucracy. Patients often face uncertainty, delays, and medical debt despite the existence of these programs.

• Over $40 billion is spent annually on care for the uninsured, mostly government-funded.
• Many eligible individuals do not enroll due to complexity or lack of awareness.
• Hospitals often sue patients eligible for charity care.

5. Universal Health Insurance Is the Only Sensible Way to Formalize and Fulfill This Enduring Social Commitment.

As long as it is an unavoidable function of government to try to provide health care for those in need, then universal health insurance coverage is the right vehicle for fulfilling that obligation in a full and sensible manner.

Formalizing the inevitable. Given that society consistently attempts to provide essential medical care to those who are ill and cannot afford it, the most logical and efficient approach is to formalize this commitment upfront through universal health insurance. This argument dates back centuries and has been embraced across the political spectrum.

Hamilton's logic. Alexander Hamilton made this case in 1798 for compulsory health insurance for seamen: since society would inevitably bear the cost of caring for sick sailors far from home, it made sense to formalize and fund this care through mandatory contributions. This same logic applies today to the broader population.

Modern consensus. Prominent figures from diverse ideological backgrounds agree that since society will ultimately pay for the care of the uninsured, mandatory or automatic universal coverage is the most rational approach.

• Justice Ruth Bader Ginsburg cited the reality of hospitals providing care regardless of ability to pay as a rationale for the ACA mandate.
• Conservative economist F.A. Hayek argued that if society provides for extreme needs, it's a "corollary to compel them to insure."
• Republican Governor Mitt Romney framed the Massachusetts mandate as ending "free riders" who rely on others when they get sick.

6. The Purpose of Universal Coverage Is to Ensure Adequate Basic Care for All, Not to Achieve Health Equality.

access to good doctors and hospitals will lengthen your life if you have a heart attack, but simply not having a heart attack (or delaying its onset) will have a far greater impact on longevity.

Health vs. health care. While health disparities in the U.S. (by income, race) are enormous and distressing, health insurance policy is not the primary tool to address them. Research shows that differences in access to medical care or insurance are not the main drivers of these disparities.

Beyond the clinic. Factors outside the healthcare system, known as social determinants of health, play a much larger role in overall health outcomes and life expectancy.

• Geographic location (zip code) is a strong predictor of health.
• Health behaviors (smoking, diet, exercise) are crucial.
• Health literacy and knowledge within families matter.

Adequacy, not equality. The social contract revealed by U.S. history is about ensuring a basic standard of essential medical care for everyone, regardless of resources – a standard of adequacy. It is not a commitment to ensure equal health outcomes or equal access to all possible medical services.

A multi-tiered system is compatible. Philosophers like Norman Daniels argue that justice requires access to care necessary for "normal species functioning" and fair opportunity, but this is compatible with a system where those with resources can purchase additional, non-essential care or amenities. Historically, U.S. hospitals provided tiered care based on ability to pay, focusing on a basic standard for all.

7. Basic Universal Coverage Must Be Automatic and Completely Free for Patients at the Point of Service.

Basic Coverage to Be Automatic.

Automatic enrollment is key. Achieving truly universal coverage requires providing it automatically, without requiring individuals to navigate complex enrollment processes or remember to re-enroll. The U.S. experience with Medicare for the elderly demonstrates the success of this approach, achieving near-universal coverage efficiently. Mandates alone, like the ACA's (when it had a penalty), are insufficient without automatic enrollment and rigorous enforcement.

Taxpayer financing is necessary. For coverage to be automatic, it must be financed by the government through tax revenue, not through individual premiums. Charging premiums for basic coverage is incompatible with providing it as an entitlement to everyone, regardless of their ability to pay those premiums.

No patient fees. Any medical care included in basic coverage must be provided completely free to the patient at the point of service (no co-pays, deductibles, or coinsurance). While economists have long argued for cost-sharing to reduce utilization (based on the RAND experiment), this undermines the fundamental purpose of insurance: protecting against financial risk.

• Substantial cost-sharing exposes patients to unaffordable bills and debt.
• Even small fees create access barriers for the poorest.
• Countries with cost-sharing inevitably add complex, burdensome exemption programs (UK, Germany, France), adding complexity without significant savings.

8. Basic Coverage Should Be Truly Basic, Prioritizing Essential Medical Function Over Amenities and Unlimited Choice.

Basic coverage should be very basic.

Focus on health, not care amenities. Basic coverage should prioritize restoring or maintaining essential human function ("health") rather than providing luxurious amenities or unlimited convenience ("care"). This distinction is crucial for keeping taxpayer costs manageable while fulfilling the social contract.

Minimalist amenities. Non-medical aspects of care can be quite basic. Examples from other countries include:

• Multi-bed hospital rooms with shared bathrooms and minimal comforts (Singapore, Australia).
• Less comfortable waiting areas.
• Standard food options.

Managed access. Basic coverage should involve gatekeeping mechanisms, unlike the current fee-for-service Medicare. Requiring referrals to specialists or prior authorization for certain procedures helps ensure appropriate care and control costs, acting like a "general contractor" for patient treatment. While gatekeeping has trade-offs (potential delays, reduced patient choice), it is a necessary component of a sensible basic system.

Reasonable wait times. Access to non-emergency care doesn't need to be instantaneous. While excessively long waits are unacceptable,
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Last updated: May 19, 2025