A Conservative Blueprint for Universal Healthcare

— Achieving universal coverage is possible using the ACA as a framework

by
Cedric Dark, MD, MPH



March 23, 2023

I recently read “A Republican Argument for Affordable Universal Healthcare” in MedPage Today. While it is pleasing to see that some Republicans agree that universal healthcare is a laudable goal, it is disconcerting that conservative policymakers still lack a clear vision and framework for how to achieve that ideal. Fortunately, the conservative principles of private industry, personal responsibility, and limited government can be applied to health insurance. Reformers in other countries such as Germany, Switzerland, the Netherlands, and Singapore have provided clear examples of how to achieve, what I would consider to be, a Republican vision of a universal healthcare system. It’s now up to our politicians in the U.S. to implement the blueprint.

Theodore Roosevelt, during his 1912 campaign, proposed studying Germany’s healthcare system — one composed of several nongovernmental “sickness funds” used to cover all its citizens with private health insurance. In 1989, a policy analyst at a leading conservative Washington, D.C. think tank described a workable plan in which private insurers, just as in Germany, provide universal coverage. This plan would:

1. Change the current tax treatment of health insurance (which largely benefits people with employer-based coverage at the expense of lower income Americans)
2. Declare that families face the responsibility of having adequate insurance
3. Offer government assistance to families unable to afford health coverage on their own
4. Reform the Medicare program

The middle planks of this conservative plan ultimately became the Affordable Care Act’s (ACA) Marketplaces, where families could purchase health insurance in a new, nationally regulated market with financial subsidies to cover costs for those with incomes below 400% of the federal poverty level (about $92,120 for a family of three).

President Barack Obama signed the ACA into law 13 years ago today, transforming a patchwork system of individual health insurance markets into one that today could form a national framework for universal healthcare. As opposed to the single payer system that progressive politicians like Sen. Bernie Sanders (I-Vt.) and Rep. Pramila Jayapal (D-Wash.) propose, an “ACA for All” system would prevent government from operating health insurance while allowing it to regulate and finance health insurance for most Americans. The ACA for All would not be “socialized medicine” — where government not only finances healthcare but supplies it through public hospitals, clinics, and the direct employment of clinicians. ACA for All would continue to rely on private industry (private doctors and private hospitals) and personal responsibility, and would limit the government’s role in healthcare delivery.

First, a new system could tackle the unfair and variable tax benefit that Americans with employer-based insurance currently receive (with greater benefits for those in higher income brackets) and help finance care for 27.5 million uninsured, non-elderly Americans. How might this work? A Republican plan for universal healthcare would offer those with non-employer-based coverage an adequately sized tax deduction, big enough to cover the cost of a family health insurance plan. And, for the first time since the 1940s, individuals would pay taxes on the value of employer-based health insurance above a certain threshold (based on the average cost of a family health insurance plan). This would also assert pressure to limit the unchecked rise of insurance premiums. Essentially, this new model would put both versions of coverage — individual and employer — on the same tax footing.

Second, Americans without employer coverage would use the current ACA Marketplaces to purchase coverage for their families (as they can now). But, commensurate with proof of coverage would come the tax benefits currently only afforded to individuals with employer plans. The current ACA subsidy structure, enhanced by the Inflation Reduction Act, ensures that financial assistance is available to families who would otherwise pay more than 8.5% of income for health insurance. This guarantee of limiting health costs to a specific percentage of household income should continue.

Third, over 2 million Americans remain in a coverage gap caused by states that have yet to expand Medicaid. A Republican plan for universal healthcare would eliminate Medicaid as we know it, and instead fold these Americans into the ACA Marketplaces to buy their own private insurance plan. Instead of utilizing public coverage, low-income Americans below the poverty line would use subsidies and cost-sharing assistance to make private health insurance available to them at no cost. And by removing the collective $29.5 billion administrative burden required to run Medicaid, states could focus other priorities such as public safety and public education.

Fourth, Americans above the age of 65 currently enjoy access to the federally-run Medicare program. Medicare is a single-payer plan for seniors where those currently in the workforce pay for retirees’ healthcare needs. Nearly half of seniors currently choose Medicare Advantage, a privately administered form of Medicare, with enrollment steadily rising over the past 2 decades. In this new system, America would have its seniors simply purchase their healthcare plan from among the choices in the ACA Marketplaces as all other Americans without employer-based insurance would do. Seniors would be offered subsidies to cover their premiums on par with current standards. In 2019, seniors spent over $6,000 on premiums and cost sharing in Medicare, amounting to paying for over 31% of their healthcare bills out of their own pockets. Under a Republican plan, no senior would spend more than 8.5% of their retirement income on healthcare.

For Republicans to champion universal healthcare, the best framework to build upon is, ironically, the ACA, President Obama’s signature law, which Congressional Republicans have fought to repeal and replace for over a decade. Republicans, however, must change course, and expand the ACA for all Americans including seniors, the poor, and families who do not have coverage from their employers. The plan I have described above provides the blueprint. Let’s use it for positive change.

Cedric Dark, MD, MPH, is a practicing emergency physician in Houston.