Lessons from the COVID 19 Pandemic: The Importance of Universal Health Care in Addressing Health Care Inequities

  • Date: Oct 26 2021
  • Policy Number: 202112

Key Words: Health Insurance, Health Equity, Health Reform, , 

Abstract
The COVID pandemic has added a new sense of urgency to establish a universal health care system in the United States. Our current system is inequitable, does not adequately cover vulnerable groups, is cost prohibitive, and lacks the flexibility to respond to periods of economic and health downturns. During economic declines, our employer-supported insurance system results in millions of Americans losing access to care. While the Affordable Care Act significantly increased Americans’ coverage, it remains expensive and is under constant legal threat, making it an unreliable conduit of care. Relying on Medicaid as a safety net is untenable because, although enrollment has increased, states are making significant Medicaid cuts to balance budgets. During the COVID-19 pandemic, countries with universal health care leveraged their systems to mobilize resources and ensure testing and care for their residents. In addition, research shows that expanding health coverage decreases health disparities and supports vulnerable populations’ access to care. This policy statement advocates for universal health care as adopted by the United Nations General Assembly in October 2019. The statement promotes the overall goal of achieving a system that cares for everyone. It refrains from supporting one particular system, as the substantial topic of payment models deserves singular attention and is beyond the present scope.

Relationship to Existing APHA Policy Statements
We propose that this statement replace APHA Policy Statement 200007 (Support for a New Campaign for Universal Health Care), which was set to archive in 2020. The following policy statements support the purpose of this statement by advocating for health reform:

  • APHA Policy Statement 200911: Public Health’s Critical Role in Health Reform in the United States
  • APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health

In addition, this statement is consistent with the following APHA policies that reference public health’s role in disaster response:

  • APHA Policy Statement 20198: Public Health Support for Long-Term Responses in High-Impact, Postdisaster Settings
  • APHA Policy Statement 6211(PP): The Role of State and Local Health Departments in Planning for Community Health Emergencies 
  • APHA Policy Statement 9116: Health Professionals and Disaster Preparedness
  • APHA Policy Statement 20069: Response to Disasters: Protection of Rescue and Recovery Workers, Volunteers, and Residents Responding to Disasters 

Finally, this policy statement is consistent with and updates older policies as well as the original late-breaker version of this statement:

  • APHA Policy Statement 200910: Improving Access to Vision Care in Community Health Centers
  • APHA Policy Statement 20161: Access to Integrated Medical and Oral Health Services
  • APHA Policy Statement 7711: Dental Health in a National Health Program
  • APHA Policy Statement 9005: Need for Coverage of In Home and Community Based Long Term Care
  • APHA Policy Statement 8731PP: Toward a Comprehensive National Policy on Catastrophic Acute and Long Term Health Care
  • APHA Policy Statement LB20-06: The Importance of Universal Health Care in Improving Our Nation’s Response to Pandemics and Health Disparities

Problem Statement
Background: The United States spends more on health care (16.8% in 2019) than any other industrialized country yet has worse health outcomes.[1,2] Public health receives 2.9% of that spending despite the fact that we have the most preventable deaths.[3] Discussions around universal health care in the United States started in the 1910s and have resurfaced periodically.[4] President Franklin D. Roosevelt attempted twice in the 1940s to establish universal health care and failed both times.[4] Eventually, the U.S. Congress passed Medicare and Medicaid in the 1960s. Universal health care more recently gained attention during debates on and eventual passage of the Affordable Care Act (ACA).[5] There also have been decades of political animosity toward health care reform in the United States, with failed attempts in the Nixon and Clinton administrations and numerous failed attempts to repeal and challenge the ACA.[6]

To date, the U.S. government remains the largest payer of health care in the United States, covering nearly 90 million Americans through Medicare, Medicaid, TRICARE, and the Children’s Health Insurance Program (CHIP).[7] However, this coverage is not universal, and many Americans were uninsured[8] or underinsured[9] even before the COVID-19 pandemic began in 2020. 
 
Pandemics exacerbate underlying issues in our current health care system and highlight the urgent need for universal health care for all Americans. 

Health care is inaccessible for many individuals in the United States: For many Americans, accessing health care is cost prohibitive.[10] Coverage under employer-based insurance is vulnerable to fluctuations in the economy. Due to the COVID-19 pandemic, an estimated 20 million Americans had lost their employer-sponsored health insurance by September 2021 as a result of job loss.[11] Job losses were not distributed evenly and particularly affected those in low-paying, service-sector positions, thereby disproportionately affecting individuals of lower socioeconomic status.[12] When uninsured or underinsured people refrain from seeking care secondary to cost issues, this leads to delayed diagnosis and treatment, promotes the spread of a pandemic pathogen, and may increase overall health care system costs. 

The ACA reformed health care by, for instance, eliminating exclusions for preexisting conditions, requiring coverage of 10 standardized essential health care services, capping out-of-pocket expenses, and significantly increasing the number of insured Americans. However, many benefits remain uncovered, and out-of-pocket costs can vary considerably. For example, an ACA average deductible ($3,064) is twice the rate of a private health plan ($1,478).[8] Those living with a disability or chronic illness are likely to use more health services and pay more. A recent survey conducted during the COVID-19 pandemic revealed that 38.2% of working adults and 59.6% of adults receiving unemployment benefits from the Coronavirus Aid, Relief, and Economic Security (CARES) Act could not afford a $400 expense, highlighting that the COVID-19 pandemic exacerbated lack of access to health care because of high out-of-pocket expenses.[13] In addition, the ACA did not cover optometry or dental services for adults, thereby inhibiting access to care even among the insured population.[14] A 2019 study by the Commonwealth Fund[15] showed that after 10 years of implementation, 45% of adults 19 to 64 years of age enrolled in the ACA were underinsured, defined as having out-of-pocket health care expenses of 10% or more of one’s income (or 5% or more for those up to 200% above the federal poverty limit). 
 
Our current health care system cannot adequately respond to the pandemic and supply the care it demands: The pandemic reminded the world of the vital role of public health.[16–19] The lack of a national public health coordinated response has been cited as a central reason for the poor early mitigation of the COVID-19 pandemic in the United States in 2020.[20] The Healthy People 2030 goals also provide ways for public health to contribute to a variety of national priorities in primary prevention efforts well beyond pandemics.[21]

As in other economic downturns wherein people lost their employer-based insurance, more people enrolled in Medicaid during the pandemic. States’ efforts to cover their population, such as expanding eligibility, allowing self-attestation of eligibility criteria, and simplifying the application process, also increased Medicaid enrollment numbers.[22] The federal “maintenance of eligibility” requirements further increased the number of people on Medicaid by postponing eligibility redeterminations. While resuming eligibility redeterminations will cause some to lose coverage, many will remain eligible because their incomes continue to fall below Medicaid income thresholds.[22] 

An urgent need for coverage during the pandemic exists. Virginia’s enrollment has increased by more than 40% since March 2020.[23] In Arizona, 78,000 people enrolled in Medicaid and CHIP in two months.[24] In New Mexico, where 42% of the population was already enrolled in Medicaid, 10,000 more people signed up in the first two weeks of April than expected before the pandemic.[24] Nearly 24 million people who lost their jobs during the pandemic could be eligible for Medicaid.[25] Even in September 2021, the leisure and hospitality sector had a job shortfall of nearly 1.6 million relative to February 2020. The number of long-term unemployed (those jobless for 27 weeks or more) decreased by 496,000 in September to 2.7 million but was 1.6 million higher than in February 2020.[26] 

While increasing Medicaid enrollment can cover individuals who otherwise cannot afford care, it further strains state budgets.[24] Medicaid spending represents a significant portion of states’ budgets, making it a prime target for cuts. Ohio announced $210 million in cuts to Medicaid, a significant part of Colorado’s $229 million in spending cuts came from Medicaid, Alaska cut $31 million in Medicaid, and Georgia anticipates 14% reductions overall.[24] 
 
While Congress has authorized a 6.2% increase in federal Medicaid matching during the pandemic, this increase was not permanently expanded (through 2021)[27] and is unlikely to sufficiently make up the gap caused by increased spending and decreased revenue.[28] Given the severity and projected longevity of the pandemic’s economic consequences, many people will remain enrolled in Medicaid throughout state and federal funding cuts. This piecemeal funding strategy is unsustainable and will strain Medicaid, making accessibility even more difficult for patients. 
 
Our health care system is inequitable: Our inequitable health care system continues to sustain structural racism.[29,30] Racial disparities are embedded in our health care system and lead to worse COVID-19 health outcomes in minority groups.[31–33]

The first federal health care program, the medical division of the Freedmen’s Bureau, was established arguably out of Congress’s desire for newly emancipated slaves to return to working plantations in the midst of a smallpox outbreak in their community rather than out of concern for their well-being.[34] An effort in 1945 to expand the nation’s health care system actually reinforced segregation of hospitals.[34] Moreover, similar to today, health insurance was employer based, making it more difficult for Black Americans to obtain. 

Although the 1964 Civil Rights Act outlawed segregation of health care facilities receiving federal funding and the 2010 ACA significantly benefited people of color, racial and sexual minority disparities persist today in our health care system. For example, under a distribution formula set by the U.S. Department of Health and Human Services (DHHS), hospitals reimbursed mostly by Medicaid and Medicare received far less federal funding from the March 2020 CARES Act and the Paycheck Protection Program and Health Care Enhancement Act than hospitals mostly reimbursed by private insurance.[35] Hospitals in the bottom 10% based on private insurance revenue received less than half of what hospitals in the top 10% received. Medicare reimburses hospitals, on average, at half the rate of private insurers. Therefore, hospitals that primarily serve low-income patients received a disproportionately smaller share of total federal funding.[35] 
 
Additional barriers for these communities include fewer and more distant testing sites, longer wait times,[36] prohibitive costs, and lack of a usual source of care.[37] Black Americans diagnosed with COVID-19 are more likely than their White counterparts to live in lower-income zip codes, to receive tests in the emergency department or as inpatients, and to be hospitalized and require care in an intensive care unit.[38] Nationally, only 20% of U.S. counties are disproportionately Black, but these counties account for 52% of COVID-19 diagnoses and 58% of deaths.[39] The pre-pandemic racial gaps in health care catalyzed pandemic disparities and will continue to widen them in the future. As of September 2021, COVID-19 vaccination rates among Hispanic, Black, Native American, and Asian/Pacific Islander individuals were below the rate among their White counterparts.[40]
 
Our health care system insufficiently covers vulnerable groups: Health care access barriers, poor integration with public health, and lack of investment in at-risk communities have been primary contributing factors in why people of color have been among the hardest hit by the COVID-19 pandemic.[31,32] About 14 million U.S. adults needed long-term care in 2018.[41] Medicare, employer-based insurance, and the ACA do not cover home- and community-based long-term care. Only private long-term care insurance and patchwork systems for Medicaid-eligible recipients cover such assistance. For those paying out of pocket, estimated home care services average $51,480 to $52,624 per year, with adult day services at more than $19,500 per year.[42] 
 
Our current health care system also inadequately supports individuals with mental illness. APHA officially recognized this issue in 2014, stating that we have “lacked an adequate and consistent public health response [to behavioral health disorders] for several reasons” and that the “treatment of mental health and substance use disorders in the United States has been provided in segregated, fragmented, and underfunded care settings.”[43] 

Our health care system has fragmented data collection systems and inconsistent enforcement of basic public health strategies to protect public safety such as isolation, quarantine, masking, infection testing, and vaccination. [44] Our system has been doubly challenged by historic underinvestments in public health infrastructure and an inability to mount a coordinated national response linking our medical and public health data systems, messaging, and outreach.[45,46]

In summary, the COVID-19 pandemic has brought urgency to the universal health care discussion in the United States. This is an unprecedented time, and indeed the pandemic has ¬¬exacerbated many of the existing problems in our current patchwork health care system. The COVID-19 pandemic represents a watershed moment where we can reconstruct a fractured health insurance system into a system of universal health care. As new data emerge about those most impacted by the pandemic, this is also a unique opportunity to address the needs of the underserved, the most vulnerable, and those historically denied or left out of health services by expanding benefits. If we can drive to homebound people’s houses to vaccinate them, we can reimagine boundaries to make home- and community-based disability services, dental care, vision services, prescription drugs, chiropractic care, mental health care, and telemedicine standard practice. We also recognize the essential role of ensuring that public health remains an integral part of universal health care in order to advance population health challenges such as effective and timely pandemic responses and social determinants of health. 
 
Evidence-Based Strategies to Address the Problem 
Our current system is inaccessible, inflexible, and inequitable, and it insufficiently covers vulnerable populations. Here we present supporting evidence that universal health care can help address these issues. 
 
Universal health care can increase accessibility to care: While individuals in the United States lost health care coverage during the pandemic, individuals in countries with universal health care were able to maintain access to care.[47–49] Some European and East Asian countries have continued to offer comprehensive, continuous care to their citizens during the pandemic. 

Twelve developed countries have universal health care systems that cost less and cover more of their residents than the fragmented health care systems of the United States. Among these systems are different models of implementation. They may be managed federally, centrally with some regional involvement, or regionally. They also vary as to their financing structures, guaranteed benefits, and out-of-pocket costs for health care consumers.[50,51] Most do not fully cover all benefits under single-payer financing. For example, in Canada there is no nationally defined statutory benefit package, and coverage decisions are made at the provincial government level. About 67% of Canadians also have supplemental private insurance to assist with services such as outpatient prescription drugs, mental health care, vision care, dental care, home care, midwifery services, medical equipment, and hospice care.[2] Germany and Canada have some cost sharing but cap or eliminate it on the basis of income, service category, or health condition.[51] In 2021, Canada and Germany had vaccination rates of 76% and 65%, respectively, with relatively little controversy among the population about the need to be vaccinated.[52]

Taiwan’s single-payer national health insurance covers more than 99% of the country’s population, allowing easy access to care.[48] Also, with this level of access, the country’s residents were offered coronavirus tests free of charge, and there were sufficient hospital isolation rooms for patients with confirmed and suspected cases of COVID-19.[49] In 2021, Taiwan had one of the lowest incidence rates in the world, with only 16,000 cases. In terms of vaccinations, Taiwan has lagged behind other countries. 

Thai epidemiologists credit their universal health care system with controlling the COVID-19 pandemic.[53] They have described how their first patient, a taxi driver, sought medical attention unencumbered by doubts about paying for his care. In 2021, they still benefited from one of the lowest caseloads in the world.[53] In terms of vaccinations, Thailand has administrated nearly 59 million doses and 43% of its population is vaccinated, with COVID rates falling.[52]
 
Universal health care is a more cohesive system that can better respond to health care demands during a pandemic and in future routine care: Leveraging its universal health care system, Norway began aggressively tracking and testing known contacts of individuals infected with COVID-19 as early as February 2020. Public health officials identified community spread and quickly shut down areas of contagion. By April 30, 2020, Norway had administered 172,586 tests and recorded 7,667 positive cases of COVID-19[47]. Experts attribute Norway’s success in early contagion mitigation, in part, to its universal health care system.[47] Norway’s early comprehensive response and relentless testing and tracing benefited the country’s case counts and mortality outcomes.[47] In terms of vaccinations, Norway has administrated nearly 8 million doses and 74% of its population is vaccinated, with COVID rates falling.[52] 

Australia’s universal health care system was reported as a central component of the country’s successful early COVID-19 response. Australia instituted a nationwide coordinated response that included the ability to use its available data systems and to assemble representatives working in public health, in primary care, and in coordination with vulnerable groups (e.g., Aboriginal communities). The country credited its successful emergency response—even before a vaccine was available—to its ability to have more consistent and unified messaging, build trust among the public, and align medical care, policymakers, and meaningful public health engagement with different communities to identify their needs.[54] 

Once China released the genetic sequence of COVID-19, Taiwan’s Centers for Disease Control laboratory rapidly developed a test kit and expanded capacity via the national laboratory diagnostic network, engaging 37 laboratories that can perform 3,900 tests per day.[49] Taiwan quickly mobilized approaches for case identification, distribution of face masks, containment, and resource allocation by leveraging its national health insurance database and integrating it with the country’s customs and immigration database daily.[25] Taiwan’s system proved to be flexible in meeting disaster response needs. 
 
Although these countries’ success in containing COVID-19 and their individual vaccine roll-outs varied, their universal health care systems allowed comprehensive responses. 

Universal health care can help increase access to care while decreasing disparities in health: Several factors point to decreased racial and ethnic disparities under a universal health care model. CHIP’s creation in 1997 covered children in low-income families who did not qualify for Medicaid; this coverage is associated with increased access to care and reduced racial disparities.[55] Similarly, differences in diabetes and cardiovascular disease outcomes by race, ethnicity, and socioeconomic status decline among previously uninsured adults once they become eligible for Medicare coverage.[56] While universal access to medical care can reduce health disparities, it does not eliminate them; health inequity is a much larger systemic issue that society needs to address. 
 
Universal health care better supports the needs of vulnerable groups: It is estimated that the lifetime risk of need for long-term care and support services is about 52% among Americans 65 years or older.[57] Activities of daily living programs are not considered “medical care” and are not covered by Medicare or health plans. Medicaid buy-in programs for workers with disabilities exist in many states but have varying benefit levels and eligibility restrictions.[58] The United States can adopt strategies from existing models in other countries with long-term care policies already in place. For example, Germany offers mandatory long-term disability and illness coverage as part of its national social insurance system, operated since 2014 by 131 nonprofit sickness funds.[59] German citizens can receive an array of subsidized long-term care services without age restrictions.[59] 
 
Universal health care can also decrease health disparities among individuals with mental illness. For instance, the ACA Medicaid expansion helped individuals with mental health concerns by improving access to care and effective mental health treatment.[60,61] California’s Mental Health Equity Parity and Addiction Act of 2008 could serve as another benefit model.[62] 

Opposing Arguments/Evidence 
Universal health care is more expensive: In 1968, spending on major U.S. government health care programs represented 0.7% of the gross domestic product (GDP); in 2018 it represented 5.2% of the GDP, and it is projected to represent 6.8% in 2028.[63] Moreover, universal health care may add $32.6 trillion to the federal budget during the first 10 years and equal 10% of the GDP in 2022.[64] 

Counterpoint: Some models of single-payer universal health care systems estimate savings of $450 billion annually.[65] Others estimate $1.8 trillion in savings over a 10-year period.[66] In 2019, 17% of the U.S. GDP was spent on health care; comparable countries with universal health care spent, on average, only 8.8%.[67] The so-called “Bismark model” of highly regulated insurance, as seen in Germany and France, also controls costs.[50,51]
 
Counterpoint: Health care services in the United States are more expensive than in other economically comparable countries. For example, per capita spending on inpatient and outpatient care (the biggest driver of health care costs in the United States) is more than two times greater even with shorter hospital stays and fewer physician visits.[68] Overall, the United States spends over $5,000 more per person in health costs than countries of similar size and wealth.[68] 

Counterpoint: Universal health care will be too difficult to implement in the United States. There is a growing recognition that the ACA has been both popular among those formerly uninsured and flawed in terms of access and cost containment. This, together with a worldwide pandemic, has sharpened the focus on the need for health care reform and in particular health equity. A 2019 Congressional Budget Office report on Medicare for all described displacement among health care administrative workers, likely with some workers finding employment with the government. Universal health care implementation will be complex and require coordination of an expert health care planning team. The details of implementation will differ substantially depending on how many existing systems remain and the timeline for change. 

Counterpoint: Administrative costs are lower in countries with universal health care. The United States spends four times more per capita on administrative costs than similar countries with universal health care.[69] Nine percent of U.S. health care spending goes toward administrative costs, while other countries average only 3.6%. In addition, the United States has the highest growth rate in administrative costs (5.4%), a rate that is currently double that of other countries.[69] 

Universal health care will lead to rationing of medical services, increase wait times, and result in care that is inferior to that currently offered by the U.S. health care system: Opponents of universal health care point to the longer wait times of Medicaid beneficiaries and other countries as a sign of worse care. It has been shown that 9.4% of Medicaid beneficiaries have trouble accessing care due to long wait times, as compared with 4.2% of privately insured patients.[70] Patients in some countries with universal health care, such as Canada and the United Kingdom, experience longer wait times to see their physicians than patients in the United States.[71] In addition, some point to lower cancer death rates in the United States than in countries with universal health care as a sign of a superior system.[71] 
 
Another concern is rationing of medical services due to increased demands from newly insured individuals. Countries with universal health care use methods such as price setting, service restriction, controlled distribution, budgeting, and cost-benefit analysis to ration services.[72] 
 
Counterpoint: The Unites States already rations health care services by excluding patients who are unable to pay for care. This entrenched rationing leads to widening health disparities. It also increases the prevalence of chronic conditions in low-income and minority groups and, in turn, predisposes these groups to disproportionately worse outcomes during the pandemic. Allocation of resources should not be determined by what patients can and cannot afford. This policy statement calls for high-value, evidence-based health care, which will reduce waste and decrease rationing. 
 
Counterpoint: Opponents of universal health care note that Medicaid patients endure longer wait times to obtain care than privately insured patients[70] and that countries with universal health care have longer wait times than the United States.[71] However, in one survey, 22% of Americans said that they delayed health care because they could not afford it[73]; furthermore, in a survey of 1,000 U.S. physicians, 92% of respondents agreed that insurance preauthorization delays negatively impacted their patients.[74] Although the United States may enjoy shorter wait times, this does not translate into better health outcomes. For instance, the United States has higher respiratory disease, maternal mortality, and premature death rates and carries a higher disease burden than comparable wealthy countries.[74] Unfortunately, these conditions may have involved higher mortality rates during the pandemic due to strained hospital services. 
 
Counterpoint: A review of nearly a dozen countries’ health care systems suggests that broader coverage increases access to care and improves population health.[75] 

Counterpoint: While it is reasonable to assume that eliminating financial barriers to care will lead to a rise in health care utilization because use will increase in groups that previously could not afford care, a review of the implementation of universal health care in 13 capitalist countries revealed no or only small (less than 10%) post-implementation increases in overall health care use.[76] This finding was likely related to some diseases being treated earlier, when less intense utilization was required, as well as a shift in use of care from the wealthy to the poorest.[76] 

There were preexisting weaknesses in the public health infrastructure and the Centers for Disease Control and Prevention, including a lack of national/state coordinated preparation for a pandemic. 

Counterpoint: Indeed, there were many preexisting weaknesses in the system. The lack of a coordinated federal and state response was one component of the problem. Nonetheless, implementing universal health care would drastically reduce the issues around public health infrastructure (e.g., testing, access to care) and assist with federal-state coordination. Considering the example of Medicaid, it functions well as a joint federal-state coordinated program. One weakness of the current Medicaid program is that recipients cannot use benefits across state lines. In a universal health care system, the beneficiary would be able to obtain his or her care in any state, which may become an important part of a cohesive, national pandemic response. 

Alternative Strategies 
States and the federal government can implement several alternative strategies to increase access to health care. However, these strategies are piecemeal responses, face legal challenges, and offer unreliable assurance for coverage. Importantly, these alternative strategies also do not necessarily or explicitly acknowledge health as a right. 
 
Expanding the ACA through Medicaid expansion: Having survived a serious Supreme Court challenge in 2020,[77] the ACA marketplace and Medicaid expansion had resulted in health coverage for 31 million Americans as of February 2021.[78] The remaining 14 states that have not done so can adopt the Medicaid expansions in the ACA, and states that previously expanded can open new enrollment periods for their ACA marketplaces to encourage enrollment.[79] Adding a public option was supported by two thirds of respondents in a 2020 national poll conducted by the Kaiser Family Foundation. Senate Bill 1033 also included this provision as part of a 2021 ACA reform package. An analysis of reforms comparing building on the ACA and add-on public options or subsidies for employer-based insurance estimated that 6.6 million Americans would still be left uninsured and that the cost would be an extra $2 trillion over 10 years.[80] While this is a strategy to extend coverage to many of those left behind, frequent legal challenges to the ACA and Medicaid cuts make it an unreliable source of coverage in the future.[80] In addition, although many people gained insurance, access to care has remained challenging due to prohibitively priced premiums and direct costs [80]. 
 
Before the pandemic, the New York state legislature began exploring universal single-payer coverage, and the New Mexico legislature started considering a Medicaid buy-in option.[81] These systems would cover only residents of a particular state, and they remain susceptible to fluctuations in Medicaid cuts, state revenues, and business decisions of private contractors in the marketplace. 
 
Federal government strategies: Congress can continue to pass legislation in the vein of the Families First Coronavirus Response Act and the CARES Act. These acts required all private insurers, Medicare, and Medicaid to cover COVID-19 testing, eliminate cost sharing, and set funds to cover testing for uninsured individuals. They fell short in requiring assistance with COVID-19 treatment. A strategy of incremental legislation to address the pandemic is highly susceptible to the political climate, is unreliable, and does not address non-COVID-19 health outcomes. Most important, this system perpetuates a fragmented response to the COVID-19 pandemic. 
 
An additional option for the federal government is to cover the full costs of Medicaid expansion in the 14 states yet to expand coverage. If states increased expansion and enforced existing ACA regulations, nearly all Americans could gain health insurance.[82] This alternative is risky, however, due to frequent legal challenges to the ACA. Furthermore, high costs to access care would continue to exist.

Action Steps 
This statement reaffirms APHA’s support of the right to health through universal health care. Therefore, 
APHA: 

  1. Urges Congress, the states, and the president, given the COVID-19 pandemic, to recognize universal health care as a right for every person residing in the United States. 
  2. Urges Congress to fund and design and the president to enact and implement a comprehensive universal health care system that is accessible, equitable, and affordable for all residents; that ensures access to rural populations, people experiencing homelessness, sexual minority groups, those with disabilities, and marginalized populations; that is not dependent on employment, medical or mental health status, immigration status, or income; that emphasizes high-value, evidence-based care; that includes automatic and mandatory enrollment; and that minimizes administrative burden. 
  3. Urges the DHHS, the Agency for Healthcare Research and Quality, the Institute of Medicine, the National Institutes of Health, academic institutions, researchers, and think tanks to examine equitable access to health care, including provision of mental health care, long-term care (including home- and community-based support), dental care, vision care, durable medical equipment, and chiropractic care. 
  4. Urges Congress, national health care leaders, academic institutions, hospitals, and each person living in the United States to recognize the harms caused by institutionalized racism and ableism in our health care system and collaborate to build a system that is equitable and just. As one tangible means of securing equity, APHA urges enforcement of the Federal Register Standards for Accessible Medical Diagnostic Equipment to meet the everyday physical access challenges of children and adults with disabilities. 
  5. Urges national health care leaders to design a transition and implementation strategy that communicates the impact of a proposed universal health care system on individuals, hospitals, health care companies, health care workers, and communities. 
  6. Urges Congress, the Centers for Disease Control and Prevention, the DHHS, and other public health partners, in light of the acute risk of international pandemics, to recognize the need for and supply adequate funding for a robust health care system, as previously supported in APHA Policy Statement 200911. 

References 
1. Organisation for Economic Co-operation and Development. OECD statistics. Available at: https://stats.oecd.org/Index.aspx?ThemeTreeId=9. Accessed August 13, 2021.
2. Tikkanen R, Abrams MK. U.S. health care from a global perspective. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019. Accessed August 13, 2021.
3. Kamal R, Hudman J. What do we know about spending related to public health in the U.S. and comparable countries? Available at: https://www.healthsystemtracker.org/chart-collection/what-do-we-know-about-spending-related-to-public-health-in-the-u-s-and-comparable-countries/#item-start. Accessed August 13, 2021.
4. Palmer K. A brief history: universal health care efforts in the US. Available at: https://pnhp.org/a-briefhistory-universal-health-care-efforts-in-the-us/. Accessed September 30, 2020. 
5. Serakos M, Wolfe B. The ACA: impacts on health, access, and employment. Forum Health Econ Policy. 2016;19(2):201–259. 
6. Oberlander J. Lessons from the long and winding road to Medicare for all. Am J Public Health. 2019;109(11):1497–1500.
7. Centers for Medicare & Medicaid Services. CMS roadmaps for the traditional fee-for-service program: overview. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/qualityinitiativesgeninfo/downloads/roadmapoverview_oea_1-16.pdf. Accessed September 30, 2020. 
8. Goldman AL, McCormick D, Haas JS, Sommers BD. Effects of the ACA’s health insurance marketplaces on the previously uninsured: a quasi-experimental analysis. Health Aff. 2018;37(4):591–599. 
9. Collins SR, Gunja MZ, Doty MM, Bhupal HK. Americans’ views on health insurance at the end of a turbulent year. Available at: https://www.commonwealthfund.org/publications/issuebriefs/2018/mar/americans-views-health-insurance-end-turbulent-year. Accessed August 28, 2020. 
10. Tolbert J, Orgera K, Singer N, Damico A. Key facts about the uninsured population. Available at: 
https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/. Accessed September 12, 2020. 
11. Banthin J, Simpson M, Buettgens M, Blumberg LJ, Wang R. Changes in health insurance coverage due to the COVID-19 recession. Available at: https://www.urban.org/research/publication/changes-healthinsurance-coverage-due-covid-19-recession. Accessed September 30, 2020. 
12. Cole B. The impact of the COVID-19 pandemic on access to health care. Available at: https://www.nasi.org/research/the-impact-of-the-covid-19-pandemic-on-access-to-health-care/. Accessed August 13, 2021.
13. Gaffney AW, Himmelstein DU, McCormick D, Woolhandler S. Health and social precarity among Americans receiving unemployment benefits during the COVID-19 outbreak. J Gen Intern Med. 2020;35(11):3416–3419. 
14. Lutfiyya MN, Gross AJ, Soffe B, Lipsky MS. Dental care utilization: examining the associations between health services deficits and not having a dental visit in the past 12 months. BMC Public Health. 2019;19(1):265. 
15. Collins SR, Bhupal HK, Doty Michelle M. Health insurance coverage eight years after the ACA: fewer uninsured Americans and shorter coverage gaps, but more underinsured. Available at: https://www.commonwealthfund.org/sites/default/files/2019-02/EMBARGOED_Collins_hlt_ins_coverage_8_years_after_ACA_2018_biennial_survey_sb_v4.pdf. Accessed August 13, 2021.
16. Martin EG, Kronstadt J. No longer invisible: the critical role of local health departments in responding to COVID-19. Available at: https://www.healthaffairs.org/do/10.1377/forefront.20200408.106373/abs/. Accessed August 13, 2021.
17. Melvin SC, Wiggins C, Burse N, Thompson E, Monger M. The role of public health in COVID-19 emergency response efforts from a rural health perspective. Prev Chronic Dis. 2020;17:200256.
18. Benjamin GC. Ensuring health equity during the COVID-19 pandemic: the role of public health infrastructure. Rev Panam Salud Publica. 2020;44:e70.
19. Schuchat A. Public health response to the initiation and spread of pandemic COVID-19 in the United States, February 24–April 21, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:551–556. 
20. Armooh T, Barton T, Burgos A, et al. Positioning America’s public health system for the next pandemic. Available at: https://bipartisanpolicy.org/report/preparing-for-the-next-pandemic/. Accessed August 13, 2021.
21. U.S. Department of Health and Human Services. Health care: Healthy People 2030. Available at: https://health.gov/healthypeople/objectives-and-data/browse-objectives/health-care. Accessed August 13, 2021.
22. Rudowitz R, Hinton E. Early look at Medicaid spending and enrollment trends amid COVID-19. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/early-look-at-medicaid-spending-andenrollment-trends-amid-covid-19/. Accessed August 14, 2020. 
23. Masters K. Boosted by expansion, Medicaid enrollment soared to more than half a million Virginians during the pandemic. Available at: https://www.virginiamercury.com/2021/07/06/boosted-by-expansion-medicaid-enrollment-soared-to-more-than-half-a-million-virginians-during-the-pandemic/. Accessed August 13, 2021.
24. Roubein R, Goldberg D. States cut Medicaid as millions of jobless workers look to safety net. 
Available at: https://www.politico.com/news/2020/05/05/states-cut-medicaid-programs-
239208. Accessed August 14, 2020. 
25. Garfield R, Claxton G, Damico A, Levitt L. Eligibility for ACA health coverage following job loss. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/eligibility-for-aca-health-coverage-following-job-loss/. Accessed August 14, 2020. 
26. US Department of Labor. The employment situation—September 2021. Available at: https://www.bls.gov/news.release/pdf/empsit.pdf. Accessed October 13, 2021.
27. Sullivan J. States to get enhanced Medicaid funding through 2021. Available at: https://www.cbpp.org/blog/states-to-get-enhanced-medicaid-funding-through-2021. Accessed August 13, 2021. 
28. Rudowitz RC, Garfield R. How much fiscal relief can states expect from the temporary increase in the Medicaid FMAP? Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-fiscalrelief-can-states-expect-from-the-temporary-increase-in-the-medicaid-fmap/. Accessed August 14, 2020. 
29. Hunt B. Understanding Health Disparities Highlighted by the Coronavirus Pandemic in South Carolina. Columbia, SC: South Carolina Institute of Medicine and Public Health; 2020.
30. Hostetter M, Klein S. Reducing racial disparities in health care by confronting racism. Available at: https://www.commonwealthfund.org/publications/2018/sep/focus-reducing-racial-disparities-health-care-confronting-racism. Accessed August 13, 2021.
31. Mein SA. COVID-19 and health disparities: the reality of “the Great Equalizer.” J Gen Intern Med. 2020;35(8):2439.
32. Owen WF, Carmona R, Pomeroy C. Failing another national stress test on health disparities. JAMA. 2020;323(19):1905–1906.
33. Chowkwanyun M, Reed Jr AL. Racial health disparities and Covid-19—caution and context. N Engl J Med. 2020;383(3):201–203.
34. Downs J. Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction. New York: Oxford University Press; 2015. 
35. Schwartz K, Damico A. Distribution of CARES Act funding among hospitals. Available at: 
https://www.kff.org/health-costs/issue-brief/distribution-of-cares-act-funding-amonghospitals. Accessed August 15, 2020. 
36. Rader B, Astley CM, Sy KTL, et al. Geographic access to United States SARS-CoV-2 testing sites highlights healthcare disparities and may bias transmission estimates. J Travel Med. 2020;27(7):76. 
37. Artiga S, Garfield R, Orgera K. Communities of color at higher risk for health and economic challenges due to COVID-19. Available at: https://www.kff.org/coronavirus-covid-19/issuebrief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/. Accessed August 15, 2020.
38. Azar K, Shen Z, Romanelli R, et al. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff. 2020;39(7):1253–1262. 
39. Millett GA, Jones AT, Benkeser D, et al. Assessing differential impacts of COVID-19 on Black communities. Ann Epidemiol. 2020;47:37–44. 
40. Centers for Disease Control and Prevention. COVID data tracker. Available at: https://covid.cdc.gov/covid-data-tracker/#vaccination-demographic. Accessed August 13, 2021.
41. Hado E, Komisar H. Long-term services and supports. Available at: https://www.aarp.org/ppi/info2017/long-term-services-and-supports.html. Accessed September 1, 2020. 
42. GenWorth Financial. Cost of care survey. Available at: https://www.genworth.com/aging-andyou/finances/cost-of-care.html. Accessed September 1, 2020. 
43. American Public Health Association. APHA Policy Statement 201415: support for social determinants of behavioral health and pathways for integrated and better public health. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policydatabase/2015/01/28/14/58/support-for-social-determinants-of-behavioral-health. Accessed September 1, 2020. 
44. Wu SX, Wu X. Stay-at-home and face mask policies inconsistent with incidence and fatality during US COVID-19 pandemic. Available at: https://www.medrxiv.org/content/10.1101/2020.10.25.20219279v2.full. Accessed August 13, 2021.
45. To K, Sridhar S, Chiu K, et al. Lessons learned 1 year after SARS-CoV-2 emergence leading to COVID-19 pandemic. Emerg Microbes Infect. 2021;10:507–535.
46. Maani N, and Galea S. COVID‐19 and underinvestment in the public health infrastructure of the United States. Milbank Q. 2020;98:250.
47. Jones A. I left Norway’s lockdown for the US: the difference is shocking. Available at: https://www.thenation.com/article/world/coronavirus-norway-lockdown/. Accessed September 1, 2020. 
48. Maizland L. Comparing six health-care systems in a pandemic. Available at: 
https://www.cfr.org/backgrounder/comparing-six-health-care-systems-pandemic. Accessed August 20, 2020. 
49. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA. 2020;323(14):1341–1342. 
50. Glied SA, Black M, Lauerman W, Snowden Sara. Considering single payer proposals in U.S.: lessons from abroad. Available at https://www.commonwealthfund.org/publications/2019/apr/considering-single-payer-proposals-lessons-from-abroad. Accessed September 15, 2020.
51. Crowley R, Daniel H, Gooney TG, Engel LS. Envisioning a better U.S. health care system for all: coverage and cost of care. Ann Intern Med. 2020;172:S7–S32.
52. Reuters. COVID-19 tracker. Available at: https://graphics.reuters.com/world-coronavirus-tracker-and-maps/countries-and-territories/germany/. Accessed October 13, 2021.
53. Gharib M. Universal health care supports Thailand’s coronavirus strategy. Available at: https://www.npr.org/2020/06/28/884458999/universal-health-care-supports-thailands-coronavirusstrategy. Accessed August 30, 2020. 
54. Desborough J, Dykgraaf S, de Toca L, et al. Australia’s national COVID-19 primary care response. Med J Aust. 2020;213:104–106. 
55. Shone LP, Dick AW, Klein JD, Zwanziger J, Szilagyi PG. Reduction in racial and ethnic disparities after enrollment in the State Children’s Health Insurance Program. Pediatrics. 2005;115(6):e697–e705. 
56. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007;298(24):2886–2894. 
57. Johnson RY. What is the lifetime risk of needing and receiving long-term services and supports? Available at: https://aspe.hhs.gov/reports/what-lifetime-risk-needing-receiving-long-term-services-supports-0#table2. Accessed August 13, 2021.
58. Kaiser Family Foundation. Medicaid eligibility through buy-in programs for working people with disabilities. Available at: https://www.kff.org/other/state-indicator/medicaid-eligibility-through-buy-in-programs-for-working-people-with disabilities/. Accessed August 13, 2021.
59. Rhee JC, Done N, Anderson GF. Considering long-term care insurance for middle-income countries: comparing South Korea with Japan and Germany. Health Policy. 2015;119:1319–1329.
60. Wen H, Druss BG, Cummings JR. Effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions. Health Serv Res. 
2015;50(6):1787–1809. 
61. Baumgartner J, Aboulafia GN, McIntosh Audrey. The ACA at 10: how has it impacted mental health care? Available at: https://www.commonwealthfund.org/blog/2020/aca-10-how-has-it-impacted-mental-health-care. Accessed August 13, 2021.
62. Steinberg D, Kennedy PJ. New California law is a national model for mental health care reform. Available at: https://www.statnews.com/2020/10/14/new-california-law-should-serve-as-a-national-model-for-mental-health-care-reform/. Accessed August 13, 2021.
63. Congressional Budget Office. Projections of federal spending on major health care programs. Available at: https://www.cbo.gov/system/files/115th-congress-2017-2018/presentation/53887presentation.pdf. Accessed October 12, 2020. 
64. Blahous C. The costs of a national single-payer healthcare system. Available at: https://www.mercatus.org/publications/government-spending/costs-national-single-payer-healthcaresystem. Accessed October 10, 2020. 
65. Galvani AP, Parpia AS, Foster EM, Singer BH, Fitzpatrick MC. Improving the prognosis of health care in the USA. Lancet. 2020;395(10223):524–533. 
66. Friedman G. Funding HR 676: the Expanded and Improved Medicare for All Act. How we can afford a national single-payer health plan. Available at: https://www.pnhp.org/sites/default/files/Funding%20HR%20676_Friedman_7.31.13_proofed.pdf. Accessed September 15, 2020. 
67. Organisation for Economic Co-operation and Development. Health expenditure and financing. 
Available at: https://stats.oecd.org/Index.aspx?ThemeTreeId=9. Accessed September 27, 2020. 
68. Kurani N, Cox C. What drives health spending in the U.S. compared to other countries? Available at: https://www.healthsystemtracker.org/brief/what-drives-health-spending-in-the-u-s-compared-to-othercountries/. Accessed September 30, 2020. 
69. Tollen L, Keating E, Weil A. How administrative spending contributes to excess US health spending. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200218.375060/abs/. Accessed August 30, 2020. 
70. U.S. Government Accountability Office. Medicaid: states made multiple program changes, and beneficiaries generally reported access comparable to private insurance. Available at: https://www.gao.gov/assets/650/649788.pdf. Accessed August 30, 2020. 
71. How Canada Compares: Results from the Commonwealth Fund’s 2016 International Health Policy 
Survey of Adults in 11 Countries. Ottawa, Ontario, Canada: Canadian Institute for Health Information; 2017. 
72. Hoffman B. Health Care for Some: Rights and Rationing in the United States since 1930. Chicago: University of Chicago Press; 2012. 
73. Saad L. More Americans delaying medical treatment due to cost. Available at: https://news.gallup.com/poll/269138/americans-delaying-medical-treatment-due-cost.aspx. Accessed August 13, 2021.
74. Kurani N, McDermott D, Shanosky N. How does the quality of the U.S. healthcare system compare to other countries? Available at: https://www.healthsystemtracker.org/chart-collection/quality-u-shealthcare-system-compare-countries/#item-start. Accessed September 20, 2020. 
75. Schneider EC, Shah A, Doty M, et al. Reflecting poorly: health care in the US compared to other high-income countries. Available at: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly. Accessed October 13, 2021.
76. Gaffney A, Woolhandler S, Himmelstein D. The effect of large-scale health coverage expansions in wealthy nations on society-wide healthcare utilization. J Gen Intern Med. 2020;35(8):2406–2417. 
77. Center on Budget and Policy Priorities. ACA survives legal challenge, protecting coverage for tens of millions. Available at: https://www.cbpp.org/research/health/aca-survives-legal-challenge-protecting-coverage-for-tens-of-millions. Accessed August 13, 2021.
78. Keith K. Record high ACA enrollment at 31 million Americans. Available at: https://www.healthaffairs.org/do/10.1377/hblog20210607.367870/full/. Accessed August 13, 2021.
79. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012;367(11):1025–1034. 
80. Blumberg LJ, Holahan J, Buettgens M, et al. Comparing health insurance reform options: from “building on the ACA” to single payer. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2019/oct/comparing-health-insurance-reform-options-building-on-aca-to-single-payer. Accessed September 15, 2020.
81. Hughes M. COVID-19 proves that we need universal health care. States are exploring their options. Available at: https://rooseveltinstitute.org/2020/06/25/covid-19-proves-that-we-need-universal-healthcare-states-are-exploring-their-options/. Accessed September 1, 2020. 
82. Blumenthal D, Fowler EJ, Abrams M, Collins SR. COVID-19—implications for the health care system. N Engl J Med. 2020;383(15):1483–1488.