I thank Jennifer Gilbert for her research assistance for this post. Her research summary is here.
The Affordable Care Act expanded, and is expected to continue to expand, coverage for health care. But it won't lead to universal coverage—unauthorized immigrants and people with lower incomes are among those less likely to become insured. Even some working and well off individuals simply choose to go uninsured. In falling short of universal coverage, the U.S. is not alone. Moreover, data from various analyses suggests the term "universal coverage" is often misapplied.
As I've come to learn, many nations that are thought of as having universal coverage don't. They leave a few groups out, like unauthorized immigrants and those with no ability to pay required premiums, in some cases. This sounds familiar! Granted, the excluded groups amount to a tiny percentage of the population in many countries, but that they exist at all begs the question of what "universal coverage" really means.
Let's look at the U.S. first. According to the CBO, by 2016 and beyond, 11% of the U.S. population will remain uninsured, including 3% that are unauthorized immigrants. Work by Rachel Nardin and David Himmelstein shows that even after ACA implementation, the uninsured are more likely to be found among lower-income groups. About 60% of the uninsured will have incomes below 200% of the federal poverty level, according to their analysis. You'll find a state-by-state breakdown of the uninsured at statehealthfacts.org.
It's not a surprise that the ACA won't achieve universal coverage, because it relies on the voluntary enrollment of individuals into insurance and, in most cases, their willingness to pay for it.*
Now let's consider some other nations. According to the OECD, "All OECD countries have universal (or quasi-universal) health coverage for a core set of health services and goods, except Mexico and the United States." Now, "quasi-universal" is a wiggle word. And, I'll grant that all OECD countries except Mexico and the U.S. have extremely high rates of insurance. But they're not all at 100%.
Greece, Slovenia, and Luxembourg are OECD member nations. Yet, the European Foundation for the Improvement of Living and Working Conditions identifies some groups without coverage in those countries. In Greece, for instance, people in debt to public authorities or health insurers can be uninsured. The same is true in Slovenia. As Jennifer Gilbert explains,
In Luxembourg, health insurance is transferred from an employer to the government automatically when one loses employment, but gains public health coverage. That coverage requires a long process and initial premium payments, and is only available to residents, so illegal immigrants and people who aren’t aware of how to navigate the process are at higher risk of losing coverage.
Bradford Gray and Ewout van Ginneken thoroughly explored the size of undocumented migrants and their insurance status in the U.S. and European countries. Even wealthy countries like Denmark, Germany, and Sweden don't guarantee access to more than emergency services to this population. That's even true in England, which most of us probably think as the (or one of the) quintessential universal coverage exemplars. In Austria, 2% of the population is uninsured.
I do not write all this to claim that the U.S. is no worse than other wealthy nations in terms of access to coverage.* We're clearly worse! I merely wish to make two points: First, true, universal coverage is a challenge for many countries, not just the U.S. Second, the types of populations that remain uninsured are similar across many countries, though differ in size and detail—they tend to be unauthorized immigrants and those facing financial challenges.
I'm a little disappointed in the way "universal coverage" is used. It seems that fewer countries achieve it than is claimed. Even the most densely knit safety nets have some holes, even if relatively small ones.
* Note: I am also not claiming that universal coverage is a morally necessary goal, as I've written.
Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.