Just over three years ago, New York City reported its first confirmed death from COVID-19. Many more followed, with over 20,000 New Yorkers dying in the devastating first wave alone. They were our relatives, friends, and neighbors.
As with so many other health workers, the memories of that time — the unimaginable suffering and tragedy — are seared in my brain forever. The freezer trucks used as portable morgues; the chaotic din inside the hospital, juxtaposed against the eerie silence of the streets; and the unsettling fear we felt, for our patients and our families.
As of this week, an estimated 15 million people will start to lose their health coverage, as the COVID-19 public health emergency ends.
But through the darkest days of the pandemic, one notion gave me succor: that finally, we would summon the will to change our broken health system. That seeing how your health affected mine — the revelation that we were bound up together — would shift the dialogue on universal health care. That with society shaken to its foundations, we would be shaken out of our complacency.
Needless to say, that hasn't happened. In fact, as of this week, an estimated 15 million people will start to lose their health coverage, as the COVID-19 public health emergency ends. And a U.S. District Court judge just struck down the part of the Affordable Care Act that provides no-cost preventive care for a range of services, such as cancer screenings, affecting 150 million people. We are missing the opportunity to cement the coverage gains made during the pandemic — and instead will move further away from the aspiration of universal health care.
Despite universal health care being the norm in almost every other wealthy country, it remains a distant possibility in the United States. A divided Congress means that bold health proposals are unlikely to advance this year or next. Yet this also opens up a window to craft a fresh political approach, particularly one that rises above the rhetorical ruts of socialized medicine and fearmongering over fictitious "death panels."
How can we advance the public dialogue on universal health care? As a practicing physician and the former health commissioner for New York City, I have meditated on this topic for years. And despite the aforementioned political challenges, there are some openings in the public discourse to advance the idea.
It starts with displacing some key narratives that have held us back. For instance, the notion that only some people are deserving of health care. This narrative particularly plagues the debate over Medicaid, seeking to draw distinctions between the deserving poor, who want to work, and the idle poor. Such a distinction ignores evidence from recent Medicaid expansions that policies like work requirements do not lead to higher rates of employment and that health coverage makes it easier to seek and hold a job. Or as The Economist, not a magazine known for its left-wing views on human nature, bluntly stated: "No, health insurance is not a disincentive to work."
Even President Richard Nixon agreed that people who are unemployed or disabled warranted support in obtaining health coverage. Fifty years ago, he argued that there was "a need to assure every American financial access to high quality health care." Clearly, conservatism can be consistent with universal health care, both historically and in the present day. When Medicaid expansion is brought directly to the ballot, it wins, including in conservative states as diverse as Idaho, Maine, Missouri, Nebraska, Oklahoma, South Dakota, and Utah. The Republican legislature in North Carolina also recently agreed to Medicaid expansion, covering 600,000 additional people statewide, by pairing it with reforms meant to increase health care competition.
North Carolina's example shows how a breakthrough on coverage can help us reach other policy priorities. The amount of oxygen taken up in political debates about coverage has narrowed the dialogue from health policy to health care policy to health insurance policy. Yet the top two concerns of the public in 2022 were strengthening the economy and reducing health care costs. Universal health care offers elected officials a path to addressing both.
Indeed, there are benefits to both workers and businesses from universal healthcare. Notably, the intertwining of health insurance with employment in the United States leads to "job lock," which puts a damper on the labor market — as well as the future prospects of workers themselves, whether seeking a higher-paying position or becoming a self-employed entrepreneur. Labor unions for low-wage workers as well as companies struggling to fill job vacancies both benefit from toppling this status quo.
About two-thirds of adults already agree it is the government's responsibility to make sure all Americans have health care coverage. Given the gridlock in our political systems, an even higher proportion will need to be persuaded to make universal health care a reality. Changing minds requires a focus on the values that move people, or what Jonathan Haidt terms "moral foundations": harm, fairness, loyalty, authority, and sanctity. While the harm and fairness domains are more important to those with liberal political leanings, conservatives place more emphasis on loyalty, authority, and sanctity.
Loyalty (as a moral foundation) can be summarized as the feeling that it's "one for all, and all for one." This was the impulse that drove us to distance and don masks in the early days of the pandemic. While that notion of self-sacrifice for the group may have tapered off during COVID-19, it also points toward the right messaging for a movement around health care for all. Fundamentally it must invoke our sense of human connection, particularly to those who are currently excluded from coverage.
The path in the United States is fraught, but it is not impossible — and there are multiple policy approaches that could start to galvanize momentum.
The faces of the uninsured, many may be surprised to learn, include veterans, family farmers, new mothers postpartum, and children. Over 6 million kids are at risk of losing coverage as the COVID-19 emergency ends, potentially doubling the uninsured rate for children. Because our identities as parents, grandparents, and caregivers are often stronger than our political identities, centering children is an important way to reset the national dialogue on universal health care.
In other countries, the path to universal health care has not always been simple. Australia adopted universal coverage, repealed it, and then re-adopted it years later — only to encounter widespread doctors' strikes lasting several months. The path in the United States is even more fraught, not least because of entrenched and politically powerful interests in the health care industry. But it is not impossible, and there are multiple policy approaches that could start to galvanize momentum: adding a public option to insurance exchanges, allowing currently ineligible individuals to buy in to Medicaid or Medicare, or radically simplifying and automating enrollment processes for individuals already eligible but not enrolled.
All of these approaches depend on enough organizing muscle to overcome political headwinds. There is latent power in tapping into the disaffection that so many clinicians feel in today's health system. Nurses' unions, for example, have already raised the issue of widespread staffing shortages successfully—and they have long been proponents of universal health care.
Martin Luther King, Jr. titled his final book, "Where do we go from here: chaos or community?" As we reflect on the last three years — and as we consider every human being who will lose their health coverage in the coming months — the American health system must grapple with the same question. King challenged the premise that the community serves the economy, telling us that is exactly backwards; that education, housing, and health care are ends in themselves. From this vantage point, universal health care is about common dignity, the idea that each of us believes in the basic worth of another's life. We may not have lived up to that standard yet, but there is a path from here.
