The health care  debate is not a new one for Americans. This perennial thorn in the nation’s political side has been around since the introduction of Medicare and Medicaid during President Lyndon B. Johnson’s administration in the 1960s. While Medicare and Medicaid have done a lot of work in ensuring access to health coverage for many of the most vulnerable Americans, they have not gone far enough toward giving every American access to health insurance.

The modern health care  debate began when former President Bill Clinton attempted to implement  compulsory insurance-based universal health care, which, according to an Oct. 28, 1993 New York Times article, would have mandated companies to pay for insurance for their workers and required individuals to be covered through one of these plans. It also included subsidies for individuals who could not afford a coverage plan and mandates for which benefits insurers must provide. However, opposition from Republicans in Congress prevented the bill from being implemented. While the Clinton health care  plan had flaws, it laid the groundwork for future advances in health care  legislation. This established the current party stances on the issue, with Democrats seeking to expand access to health care  and Republicans opposing the proposed expansions.

In 2010, former President Barack Obama’s Patient Protection and Affordable Care Act was passed into law, marking the United States’ largest expansion of health coverage since the 1960s. By 2016, the ACA reduced the uninsured rate by nearly half, according to the Henry J. Kaiser Family Foundation. This was primarily achieved through an expansion of Medicaid in all but 17 states, according to the National Conference of State Legislatures. Also contributing to the increase in Americans covered were the implementation of changes to individual insurance markets, which allowed those with pre-existing conditions to be covered, mandating that individuals buy insurance and providing insurance premium subsidies to low income individuals. While the ACA is not perfect, it has managed to bring insurance to approximately 22.8 million Americans, many of whom had never had insurance before, according to a May 14, 2015 Forbes article.

The ACA, since its initial conception, has been met with near-constant opposition from the Republican Party. Since the end of Obama’s administration, Republicans in Congress have failed in several attempts to “repeal and replace” the ACA. Republican replacement plans have been rated by the Congressional Budget Office and would have reduced the number of people with insurance by approximately 22 million over the following 10 years if they had been implemented, according to a June 26, 2017 CNBC report. A September repeal attempt, the so-called “skinny repeal,” which would have repealed the ACA without replacing it, marked the end of Republican efforts to the repeal the bill for the time being. However, the passage of the December Republican tax bill eliminated the tax mandate of the ACA. Republican proclamations of the ACA’s failure have the potential to become a self-fulfilling prophecy, as their destabilizing of the insurance market through constant repeal efforts has created turmoil and jeopardized millions of Americans’ health coverage, all in the pursuit of partisan politicking over the wellbeing of the American people. 

While Republicans made their repeal efforts, public support for the ACA grew, with a June 23, 2017 NBC/WSJ poll showing that a majority of Americans now supported the law. Despite Republican efforts to smear the ACA and a lack of support and information about enrollment, approximately nine million Americans signed up for an ACA health plan for 2018, according to a Dec. 9, 2017 Washington Post article. This leaves the nation in a precarious position, as Republicans have no viable plan to replace the ACA, but their fearmongering and elimination of the ACA tax mandate could potentially destabilize the future of the insurance and health care  industries.

Attempts to reverse the ACA’s expansion of health care lack support from the public and would leave millions of Americans uninsured, so there are two main options for health care to move forward. The first is to maintain the ACA as it exists, as a compulsory insurance based universal health care plan. This solution is simplest, as it involves little overhaul of the existing health care  industry, and there exist multiple examples for the U.S. to follow moving forward to stabilize the ACA’s individual markets.

One method would be to follow the example of Germany’s national health care  service by creating risk compensation pools to offset the adverse selection issue. Adverse selection is a term used in economics to describe a situation where buyers and sellers do not have the same information. In insurance, adverse selection describes a situation where an individual’s demand for insurance is positively correlated with their risk of loss. For example, an elderly or chronically ill individual is more likely to have a higher demand for insurance than a young, healthy individual. This creates an issue for insurance companies, as well as individuals, as it is more expensive to cover the elderly and sick than the young and healthy, leading plans for the elderly and those with pre-existing conditions to be more expensive. A risk compensation pool compensates for this issue by attempting to equalize the risk between two separate funds, one for the young and healthy, another for the elderly and people with pre-existing conditions. This works by having a fund where predominantly young and healthy clients pay into a compensation pool with funds that elderly or sick patients can withdraw from, to offset the risk taken on by the latter fund and eliminate incentive to drop elderly clients or those with pre-existing conditions. By disallowing funds to select their policyholders or deny coverage, more people are able to be insured — and at a lower cost to themselves and the insurance companies. 

Another potential solution would be to move the U.S. onto a single-payer health care system, like the one used in Canada. In a single-payer system, essential health care  costs for all citizens are financed through taxes and are covered by a single public system. In single-payer systems, there may be private health care  organizations contracted by the system, or the government may own and employ health care resources and personnel. This type of system establishes a single health risk pool for the entire population, with a single set of rules for services offered, reimbursement rates, drug fees and minimum standards of service, and it is typically extended to all citizens and legal residents.

According to a June 23, 2017 Pew Research Center poll, support for a single-payer system is growing, but many Americans still have concerns about the implications of such a move. A primary concern would be increases in individual taxes to pay for the program. While the details would need to be worked out by policymakers, in most countries with single-payer systems the increase in an individual’s taxes is far lower than the medical bills and insurance premiums they would have paid otherwise, according to a Aug. 9, 2017 Business Insider article. Another concern is the potential increase in the deficit from such a plan. However, any single-payer system would likely be replacing the existing health care  structure of Medicare, Medicaid and the ACA, so it would not be adding on top of existing entitlements but rather replacing them, and a single-payer system fully funded through taxation would not increase the deficit. In addition, providing health care  to more people at a lower cost can keep individuals from going into debt due to unexpected medical bills or the inability to get insurance, allowing for more individual consumption spending.

While the health care debate will presumably continue for many years to come, there are paths forward that would give more coverage to individuals and eventually achieve the goal of universal health care. Since Republican efforts to repeal and replace the ACA have been put to rest for the present and massive public support for the ACA has shown a public acceptance of government-funded health care , the dream of a single-payer system — and the U.S. catching up to the majority of the Western world in terms of providing basic medical needs to its citizens — is hopefully within reach.