This issue of Human Rights focuses on health and health rights, highlighting some of the extreme disparities that exist for millions of people living in the United States due to the lack of health care and health rights and making some recommendations for what we can do. As these articles point out, in contrast to many other countries, the United States does not recognize a constitutional or legal right to health or health care (unless you are in prison). This does not mean, however, that there are
The oft-repeated phrase, facts matter, applies here. This issue’s authors offer a parade of facts:
- From Khiara M. Bridges: People of color are less likely to be given appropriate cardiac care, receive kidney dialysis or transplants, or receive the best treatments for stroke, cancer, or AIDS.
- From Mary Smith: Funding of the Indian Health Service would need to nearly double to match the level of care provided to federal prisoners.
- From Erika Ziller and Andrew Coburn: The mortality rate for rural working-class whites is rising, driven by “despair deaths” from suicide, liver disease, and accidental poisoning, in particular from opioid and other drug overdoses.
- From Gretchen Borchelt: Women need more health care but are more likely to be poor and routinely forgo needed care or struggle with medical debts.
What has been happening to address disparities such as these? The articles identify three notable changes over the last 10 years. First, the Affordable Care Act (ACA)—the most significant advancement toward universal health coverage in the United States since passage of Medicare and Medicaid over 50 years ago. The ACA requires most individuals to have health insurance, provides premium supports to help lower- and middle-income people purchase insurance, bars health insurers from refusing coverage based on things like pre-existing conditions, and expands Medicaid to individuals with incomes below 138 percent of the federal poverty level (primarily childless adults who are not pregnant or eligible for Medicare). After the ACA was implemented, the rate of uninsured fell from 16 percent in 2010 to 9 percent in 2016. In those states taking up the Medicaid expansion, health access and utilization improved across the board; medical debts decreased; hospital uncompensated care decreased dramatically; rural hospitals regained footing
Second, there was an increasing awareness of
Third, there is a growing recognition that implicit (unconsciously held) biases affect
In addition to highlighting health status and significant approaches to improving health status across population groups, these articles also show that, without strong and sustained national policies in place, progress can run into a wall. Soon after taking office, President Trump announced his desire to “explode” the ACA. The Trump administration’s assault on provisions of the ACA has been relentless. Most recently, the administration took the highly unusual step of refusing to defend the constitutionality of the ACA in Texas v. United States—leaving the defense to California and 16 other states that intervened as defendants, causing three Department of Justice attorneys to refuse to sign the U.S.’s brief (one later resigned), and resulting in outcry from consumer advocates, health care providers, health insurers, small businesses, and legal scholars across the political spectrum.
The Trump administration and some states are also seeking to comprehensively transform the Medicaid program by imposing onerous restrictions on eligibility, such as work requirements (the vast majority of Medicaid recipients already work or cannot work), high premiums and co-payments (for decades, researchers have found that premiums and cost sharing shut low-income people out of necessary care), ongoing reporting requirements and lockouts for failing to submit a report (Kentucky’s program relies heavily on the Internet; however, over 60 percent of non-elderly adult Medicaid enrollees lack Internet or broadband access), and ending coverage of non-emergency Medicaid transportation (vital for rural populations). These restrictions are being challenged in court cases. Regardless of how these cases are resolved, it is clear that the Trump administration intends to tear the Medicaid safety net apart.
Whether it be Medicaid, Medicare, the Children’s Health Insurance Program, or the individual coverage offered through the ACA, over the last 60 years, our most significant advances in health and health access have occurred when health coverage has been untethered from the workplace. As these articles show, intentional, sustained, and multipronged approaches will work. On the other side of this coin, as recent upheaval shows, tying health and health care to health insurance has not resulted in a health care system that accounts for everyone, nor one that is stable. Unless we recognize health care as a public good—one that benefits individuals and whole communities—the frailty of our “system” will continue to be exposed. Access to health care and health will continue to ebb and flow with political elections and corporate profits