Several hundred cars were parked outside a food bank in San Antonio on Good Friday—the food bank fed 10,000 people that day. Such scenes, increasingly common across the nation and evocative of loaves and fish, reflect the cruel facts about the wealthiest nation in the world: 80% of Americans live paycheck to paycheck, and 100% of Americans were unprepared for the COVID-19 pandemic. People are hungry due to macroeconomic and environmental factors, not because they did something wrong. Although everyone is at risk in this pandemic, the risk is not shared equally across socioeconomic classes. Universal basic healthcare could resolve this disparity and many of the moral and economic aspects associated with the pandemic.
Increases in the total output of the economy, or the gross domestic product (GDP), disproportionately benefit the wealthy. From 1980 to 2020, the GDP increased by 79%. Over that same time, the after-tax income of the top 0.01% of earners increased by 420%, while the after-tax income of the middle 40% of earners increased by only 50%, and by a measly 20% for the bottom 50% of earners. At present, the top 0.1% of earners have the same total net worth as the bottom 85% (https://www.nytimes.com/interactive/2020/04/10/opinion/coronavirus-us-economy-inequality.html?smid=em-share). Such income inequality produces poverty, which is much more common in the US than in other developed countries. Currently 43 million Americans, or 12.7% of the population, live in poverty.
At the same time, 30 million Americans are uninsured and many more are underinsured with poorly designed insurance plans. The estimated total of uninsured and underinsured Americans exceeds 80 million (https://www.ajmc.com/newsroom/underinsured-rate-rises-although-uninsured-rate-unchanged-last-year-report-says). In addition, most of the 600,000 homeless people and 11 million immigrants in the US lack healthcare coverage. Immigrants represent an especially vulnerable population, since many do not speak English and cannot report hazardous or unsafe work conditions. Furthermore, many immigrants avoid care due to fear of deportation even if they entered the country through legal channels.
Most people in poverty and many in the middle class obtain coverage from federal programs. On a national level, Medicaid is effectively a middle-class program and covers those living in poverty, 30% of adults and 60% of children with disabilities as well as about 67% of people in nursing homes. In Iowa, 37% of children and 48% of nursing home residents utilize Medicaid. Medicaid also finances up to 20% of the care provided in rural hospitals. Medicare, Medicaid and the Children’s Hospital Insurance Program (CHIP) together cover over 40% of Americans (https://www.cms.gov/files/document/brief-summaries-medicare-medicaid-november-15-2019.pdf).
In addition to facilitating care, healthcare policy must also address the “social determinants of health,” since the conditions in which people live, work, and play dictate up to 80% of their health risks and outcomes (https://www.rwjf.org/en/our-focus-areas/topics/social-determinants-of-health.html). This means that healthcare reform requires programs in all facets of society. Winston Churchill first conceptualized such an idea in the early 20th century as a tool to prevent the expansion of socialism, arguing that inequality could persist indefinitely without social safety nets. Since that time most developed countries have implemented such social programs, but not the US.

Determinants of Health	Examples
Personal and Behavioral	diet, exercise, use of alcohol/tobacco/illicit drugs, gender/orientation
Social and Economic	education, employment, income, culture, relationships, family
Physical and Environmental	community safety/cleanliness, work conditions, access to care

All developed countries except the US provide some type of universal basic healthcare for their residents. Universal basic healthcare refers to a system that provides all people with certain essential benefits, such as emergency services (including maternity), inpatient hospital and physician care, outpatient services, laboratory and radiology services, treatment of mental illness and substance abuse, preventive health services (including vaccinations), rehabilitation, and medications. Providing access to these benefits, along with primary care, dramatically improves the health of the community without imposing concerns regarding payment. Perhaps not coincidentally, the US reports a lower life expectancy and higher rates of infant mortality, suicide and homicide compared to other developed countries (https://data.oecd.org/healthstat/life-expectancy-at-birth.htm#indicator-chart).
Countries such as Canada, Great Britain, Denmark, Germany, Switzerland, Australia, and Japan all produce better healthcare outcomes than the US at a much lower cost. In fact the US spends about twice the percentage of its GDP on healthcare compared to these countries (https://data.oecd.org/healthres/health-spending.htm). With that being said, the Affordable Care Act of 2010 (ACA), which facilitated a decrease in the rate of the uninsured in the US from 20% to 12%, also decreased the percentage of the GDP spent on healthcare from 20.2% to 17.9% in just 10 years (https://www.commonwealthfund.org/publications/issue-briefs/2019/feb/health-insurance-coverage-eight-years-after-aca). For this reason, most economists agree that universal basic healthcare would not cost more than the current system, and many would also argue that the total costs of the healthcare system cannot be further reduced unless everyone has access to basic care.
Achieving successful universal basic healthcare requires a serious long-term commitment from the federal government—contributing to Medicaid and financing its expansion are not enough. It requires courage from our elected leaders. The ACA took several important steps towards this goal by guaranteeing coverage for pre-existing conditions, banishing lifetime maximums for essential services, and mandating individual coverage for everyone, though Congress repealed this final provision in 2017. At present, the ACA requires refinement and a public option, thereby preserving private and employer-based plans for those who want them.
Without universal basic healthcare the people living at the margins of society have no assurances that they will have access to basic healthcare services, especially during times of pandemic. Access to food and medications is less reliable, large families live together in small spaces, and public transportation facilitates frequent exposure to others. Childhood diseases such as asthma, chronic diseases such as diabetes, and diseases related to smoking such as COPD and cancer are all likely to worsen. Quarantine protocols also exacerbate the mental health crisis, further increasing rates of domestic violence, child abuse, substance abuse, depression, and suicide. In the last six weeks over 30 million Americans have applied for unemployment benefits, and as people become unemployed, many will lose health insurance.
Access to basic healthcare without economic or legal consequences would greatly enhance all aspects of pandemic management and response, from tracing contacts and quarantining carriers to administering tests and reinforcing supply chains. The COVID-19 pandemic has disproportionately affected minorities and the impoverished in both mortality and livelihood. Universal basic healthcare helps these vulnerable populations the most, and by reducing their risk it reduces the risk for everyone. In this way, universal basic healthcare supports the best interests of all Americans.
Like a living wage, universal basic healthcare aligns with the Judeo-Christian tradition of social justice and is a moral and economic imperative for all Americans. Nurses, doctors, and other healthcare providers often observe a sharp contrast between the haves and have-nots when seeing patients. The homeless, the hungry, the unemployed, the working poor, the uninsured; people without families, patients with no visitors, those who live alone or lack support systems; refugees and immigrants—all of these people deserve the fairness and dignity provided by universal basic healthcare and programs which improve the social determinants of their health. The ACA moved us towards this goal, but now it requires refinement and a public option. The COVID-19 pandemic highlights the urgency of this imperative by demonstrating how universal basic healthcare could decrease the risks to those less fortunate, thus significantly decreasing the risks to everyone.

James M. Levett, MD
Dr. Levett serves on the board of Linn County Public Health and is a practicing cardiothoracic surgeon with Physicians’ Clinic of Iowa.

Pramod Dwivedi, DrPH
Dr. Dwivedi is the Director, Linn County Public Health.

Tags: Healthcare for all, Universal basic healthcare