According to a report by KFF (formerly the Henry J. Kaiser Family Foundation), released earlier this week, at least 25 million Americans they would be today without health insurance or at least some form of medical coverage. Their number would be grown up of almost 2,5 million since last December, after the Congress, with a Republican majority in both houses, has decided to do not extend with the new budget law federal subsidies for the stipulation of health insurance policies provided for by the Patient Protection and Affordable Care Act of 2010, the so-called "Obamacare”, in the form in which they were extended following the Covid-19 pandemic.
“Obamacare”
La health reform launched by the Democratic president Barack Obama sixteen years ago required residents of the United States, even those who were not American citizens, to have health insurance.
They were required to provide it. employers to their employees.
Instead, as for the rest of the population, those who could not access the pre-existing federal health care programs for those over sixty-five (Medicare) or for the poor (Medicaid), because they were not yet that old or because they did not have a sufficiently low income, they had to take out your own health insurance, under penalty of paying a fine. However, if their income, even if exceeding the poverty line, remained less than 400% of the maximum financial income to be considered indigent, they benefited from a subsidy by the federal state, usually dispensed in the form of a tax credit Awarded to insurance companies to partially cover the premiums charged to policyholders. The amount of the contribution was inversely proportional to the income level of the policyholders.
La reform had the objective This led to a drastic reduction in the number of Americans without health insurance, estimated at nearly 50 million in 2010 and dropping to around 20 million in 2016 after the measure was fully implemented. This latter figure, still relatively high for a country with just under 310 million inhabitants in 2010, was the result of the fact that Obamacare's reform did not contain mechanisms to necessarily achieve universal coverage.
The uninsured – mostly active self-employed workers – were those who they preferred to incur the payment of the administrative penalty, instead of taking out an insurance policy, for purely personal economic reasons.
In 2011, for example, the fine ranged from $695 to $2.085, depending on income, while the average annual insurance premium was $4.824. This option was also practiced by some small businesses. Businesses with fewer than fifty employees were exempt from the obligation to insure their employees if they paid a fine themselves, which, again, was generally lower than the total cost of their employees' health insurance.
The impact of Covid-19
Il 400% ceiling of the poverty line to access federal subsidies it was deleted from the American Rescue Plan Act of 2021, wanted by the Democratic president Joe Biden Among the measures to address the consequences of the coronavirus. One of the measures in the law, in fact, allowed dispense subsidies even to those who had a higher income four times what was calculated as the poverty threshold, if the cost of insurance exceeded 8,5% of one's earnings.
Circa two million Americans middle class, who until then had been excluded from the federal contribution, they took advantage of the provision to take out health insurance for the first time.
The impact of Trump's policies
After the contraction in the Obama and Biden years, the number of those who are without insurance has started to rise again. Already during his first term in the White House, President Donald Trump He had succeeded in having the administrative penalty revoked, thus encouraging people to forgo health coverage. Thus, the percentage of uninsured rose from 7,9% of the population in 2017 to 8,5% in 2018, marking the first increase in ten years.
Three months ago, however, at the end of a prolonged standoff with the Democrats in Congress – which delayed the passage of the budget law for 43 days and caused the longest shutdown (i.e. the suspension of non-essential federal administrative activities due to lack of funds) in US history, which lasted from October 1st to November 12th – Trump had it cancelled the extension of the federal contributions to the middle class, that is, to those with an income above 400% of the poverty threshold, for the purchase of insurance.
The disappearance of this benefit, which had previously also helped to calm the market, has facilitated a significant increase in the amount of insurance premiums which, according to an estimate by KFF, would have registered an increase of as much as 114%. Faced with such a significant growth, benefiting from the repeal of the fine, approximately 9% of those who had previously received federal subsidies chose not to insure, unable to afford to cover such an increase on their own. The most represented age group among those who have given up coverage is between 18 and 29 years old. These are people who count on the prospect of being less susceptible to illnesses and physical ailments thanks to their youth and, therefore, they bet on improbability of having to deal with unexpected medical emergencies in the immediate future.
The Limits of US Welfare in the Medical Field
L'health care has always represented the greater criticality of the articulations of the American welfare state, at least in the forms in which it is known in Western Europe, which start from the assumption that medical care is a right and therefore constitutes an extension of the prerogatives of citizenship in a democratic nation. In the United States, a national health service has never existed, and medical care is almost entirely based on a private system. The only exception is the care provided to former members of the armed forces who, through the Veterans Administration Health Care Sysyem, can avail themselves of public medical facilities and personnel, that is, paid and employed directly by the federal state.
Medicare and MedicaidThe previously mentioned policies are only publicly funded through the type of insurance program. In the first case, the policy is formally free for those over sixty-five, meaning it is paid for by beneficiaries through ten years of contributions deducted from their salaries for employees or from their income for the self-employed. However, those who cannot boast ten years of contributions must contribute a monthly premium, albeit a small one. In the second case, the indigent, their minor children, and certain categories of persons with serious permanent disabilities benefit from insurance through a program jointly funded by the federal government and the individual states of the Union and administered by the latter. Beneficiaries of both programs, however, benefit from treatment and hospital care provided through private performances.
The slow and troubled take-off of healthcare
The arrival at this otherwise limited system was rather tortuous in a country that has almost always made'individualism and lack of a role for the state in welfarea, not only in the medical field, a a source of national pride and boastingThe first federal social security law – the Social Security Act of 1935 – its initial wording included the establishment of mandatory health insurance. However, after realizing that the legislative process for the measure was progressing very slowly, the then president, the Democrat Franklin Delano Roosevelt, He had this clause removed from the original bill, fearing that opposition from the American Medical Association, the then-powerful medical lobby, would derail the entire project. In other words, to save aspects such as the introduction of old-age pensions, unemployment benefits, and subsidies for indigent mothers with minor children, Roosevelt was willing to sacrifice health care.
At the end of the Second World War, When the prospect of the Allied victory over Nazism gave the president the opportunity to return to domestic politics, Roosevelt tried for a second time to promote the cause of health care. In his State of the Union Address on 1944 He placed medical care among the social rights that should be recognized to American citizens and urged Congress to adopt measures to guarantee them. Nevertheless, the costs of federal intervention in the health sector were deemed excessive, especially given the significant debt from war expenses in a war that had not yet ended. Therefore, legislators ignored Roosevelt's pressure.
His successor in the White House, the Democrat, did not have better luck. Harry S. TrumanHis proposal for a Fair Deal – an expansion of the federal welfare state to include health care and thus strengthen the welfare provisions of Roosevelt's New Deal – remained a dead letter, despite Truman's confirmation as president in 1948.
It was only under the administration of another Democrat, Lyndon B. Johnson, that the federal state began to deal with medical care and hospital admissions with the Medicaid and Medicare, both launched in 1965In a global context marked by the intensification of the Cold War with the Soviet Union (for example, in the same year Washington began to participate directly in military operations in Vietnam), President Johnson felt the ideological and propagandistic need to demonstrate to the Americans and to world public opinion that the American model was superior to the communist one and, therefore, he obtained from Congress to remedy some of the most evident limitations of federal welfare, providing free treatment to the two weakest components of society: the poor and pensioners, since the latter roughly coincided with those over 65. On this occasion, unlike what had happened in 1935, the American Medical Association did not oppose it, since both categories of beneficiaries did not represent a particularly attractive clientele for doctors, due to the financial resources usually limited for pensioners and nonexistent for the poor.
Clinton's proposal
After the 1965 reform, those who were neither poor enough to qualify for Medicaid nor wealthy enough to afford private insurance were left without health coverage. The Democratic president attempted to provide for these people. Bill Clinton in 1993a bill which aimed to create a universal medical coverage. Specifically, health insurance would have been made mandatory for both self-employed and employed workers. For the latter, premiums would have been borne only by them at 20%, with the remaining 80% being paid by their employers. Furthermore, the federal government would have paid premiums for those who were unemployed, retired, or self-employed with inadequate income. The system would have continued to rely on private insurance and would have encouraged the formation of regional insurance cartels to keep premiums low.
The failure of the Clintonian project
The reform process took a long time to get off the ground. Clinton appointed a task force to design it, entrusting its co-presidency to his wife Hillary and thus arousing suspicions of nepotism, even though the position was unpaid. Furthermore, the task force produced a final report of over 1.300 pages to demonstrate in great detail how health care spending would not open new holes in the federal budget, but its length and complexity made it almost incomprehensible, outside a very small circle of insiders, compromising its promotion in public opinion.
The project was finally wrecked by theopposition from both small and medium-sized entrepreneurs, which they should have compulsorily to take on the largest share of the costs of employee insurance coverage, both of some insurance companies that hypothesized a government intervention to regulate policies with a consequent loss of profits between 30% and 60% depending on the varying degree of alarmism of the market estimates. The critics were also joined by the more progressive sectors of the Democratic party, who would have wanted the introduction of a public national health system, with the formation of a federal agency to guarantee free medical care and hospitalization for all.
The resistance of this diverse coalition of forces led to thesinking of the Clintonian reform, thanks also to a series of scandals, which had nothing to do with the management of health care, but which were artfully fabricated to divert the president's attention from gathering a majority in favor of his plan in Congress. Realizing that he did not have the votes to pass the project from the House and the Senate, Clinton preferred that it be ritirato rather than suffer the political humiliation of its rejection.
From Clinton to Bush Jr.
During Clinton's presidency, the expansion of rights in the field of health care achieved minimal results. On the one hand, the Kassebaum-Kennedy Act of 1996 allowed employees who enjoyed ahealth insurance among the fringe benefits contractual obligations to maintain it until its natural expiration, even in the case of a change of employment or dismissal, so as not to force a worker to remain tied to a particular company for the sole purpose of not being left without health coverage. On the other hand, the Children's Health Insurance Program of 1997 extended Medicaid coverage to minor children of parents who had an income above the poverty line, but could not afford to take out health insurance for their children.
Paradoxically, given the Republican Party's traditional conservative view on welfare, a significant expansion of the Welfare State in the health field occurred during the presidency of George W. Bush. Concerned about the decline in his following among the older age groups, which had put at risk his election to the White House in 2000 against the Democrat Al Gore, in 2003 Bush had Congress pass the Medicare Prescription Drug, Improvement and Modernization Act, which gave people over sixty-five the opportunity to obtain a partial refund of the price of drugs purchased with a medical prescription, the cost of which until then had been entirely borne by the patient.
The prospects for the future
“Make America healthy again” (let's make America whole again) is the reformulation of the Trump's election slogan (“Make America great again”) adopted by the current Secretary of the Department of Health and Human Services, Robert F. Kennedy Jr., essentially the equivalent of the Minister of Health of a European country. It seems, however, that the head of the ministry has done very little to achieve the goal he has set himself and has even taken positions that go in the opposite direction, such as the repeated campaigns to discourage vaccines, some of which, against all scientific evidence, Kennedy attributes to the onset of forms of autism as a side effect of administration. In any case, the aim of restoring health to Americans is seriously undermined by measures such as cuts to subsidies for taking out health insurance, as these measures significantly undermine one of the prerequisites for achieving good physical condition: the concrete possibility of being able to obtain medical care in a country where the cost of medical care is particularly high.
The KFF report mentioned at the beginning, for example, cites testimonies from Americans who have given up health insurance whose premium would have been higher than what they pay each year in installments on the mortgage taken out to purchase the house.
Overcoming this situation does not necessarily mean fully reinstating the Patient Protection and Affordable Care Act, not even in its 2021 version with the extension of subsidies. This is especially true given that Obamacare had initially abandoned the goal of achieving universal health coverage, allowing for the legislative loophole of administrative penalties far lower than the average cost of a policy, effectively allowing individuals to avoid the obligation to purchase it.
Ever since he unsuccessfully challenged Hillary Clinton for the Democratic presidential nomination in 2016, the Vermont Senator Bernie Sanders, an independent of social democratic orientation, has put forward the proposal of extend Medicare to all Americans not covered by Medicaid. According to a survey last year, the 65% of the electorate American potential would be favorable to this form of so-called “Medicare for All”, which could also supplant many private insurance plans.
Bills along these lines have been introduced several times in Congress by Sanders himself and progressive Democrats, such as Washington State Representative Pramila Jayapal. However, they have never made much headway, nor do they appear likely to do so at the moment, both because of the Republican majorities still in the Senate and the House, and because of Sanders's erroneous reputation as a dangerous socialist, which has contributed to scuppering his legislative projects in the past.
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Stefano Luconi teaches History of the United States of America in the Department of Historical, Geographical and Ancient Sciences of the University of Padua. His publications include The “Indispensable Nation”. History of the United States from its origins to Trump (2020), US institutions from the drafting of the Constitution to Biden, 1787–2022 (2022), The black soul of the United States. African Americans and the difficult path towards equality, 1619–2023 (2023). The race for the White House 2024. The election of the president of the United States from the primaries to beyond the vote of November 5 (2024).
