The US Health-Care System is One of Tiered Citizenship

The most elemental quality of citizenship is belonging: a secure place within the suite of rights, protections, and benefits a society should confer equally to everyone. Who belongs—and to what—is the political question of our time. And perhaps nowhere does that question fail our ideals more than in health care. 

Health care remains a festering wound on America’s body politic. Americans pay more for our health care than any other country in the world, nearly doubling the per-capita spend of other high-income countries. Dissatisfaction with the cost of care is one of the few issues that cuts across partisan divides: An identical 19 percent of Republican- and Democratic-leaning US adults report being satisfied with the total cost of health care.¹ Worse still, our costs are growing faster. For all that money, the US system delivers some of the worst health outcomes among comparable countries. As just one example: In 2023, the US ranked 54th in the world on infant mortality rates.²

Our health-care system simply does not show up when we need it. It is also porous, pushing more and more of the costs on patients at the point of care. Nearly 60 percent of Americans report having had problems with their insurers over the past year.³ Americans carry a collective $220 billion in medical debt⁴—more than the GDP of half of the states in the country. How does that compare to peer countries? It doesn’t, because medical debt is hardly a thing in other countries. 

But our health-care system is not only expensive and ineffectual, it also sorts us into tiers of citizenship—tiers of belonging—where some people have health insurance coverage, and many do not. The more than 25 million Americans (including 5 percent of children) who are uninsured are effectively second-class health-care citizens.⁵ In America today, someone can lose their health care for losing a job, getting a new job, turning 26, getting married, getting divorced, or striking at work—or if your employer simply wants to change insurers. Losing access to health care plunges people further into precarity, compounding an already severe epidemic of insecurity in American life. 

Even Americans with insurance coverage can be excluded from full health-care citizenship. Because health-care providers are not required to accept Medicaid, for example, its beneficiaries are, in effect, also second-class health-care citizens. It is impossible to escape the fact that reimbursing the same health-care services at a lower rate reflects an implicit lack of value of the body receiving that health-care decision. One study found that just a $10 increase in Medicaid reimbursements led to a 0.3 percent increase in the probability that a Medicaid beneficiary had seen a physician in the past two weeks.⁶ 

In our country, the best available health care comes at the price of having your biweekly or monthly paycheck garnished by a health-care company whose CEO makes eight figures. If you or your loved one does, in fact, require the care you pay for off the top of each paycheck, you still have to pay a deductible—which is now nearly $4,000 for the average family of four  earning about $80,000 per year. If you’re doing the math, it means that the average family is giving up a whole paycheck above and beyond the garnishes they give up in every other paycheck just to get health care. Beyond that, they get to decide what doctors you can see, what hospitals you can go to, and what services they’ll cover. Then there’s the insurance industry’s underhanded tactics to avoid having to pay out your claims—and that’s if you’re insured. 

What would universal health-care citizenship for all Americans mean? It could mean that every single American would have access to at least the same baseline health insurance coverage, with no deductible and no co-pays. There would be no insurance CEOs and no bloated CEO salary—and so no incentive to deny health-care coverage. There would be no network, so Americans could see whichever doctor they wanted to see and go to whatever clinic or hospital they wanted to go to. Most importantly, every single American would be covered—and no one would have to worry about losing their health insurance for simply living their life. Bringing the idea of full and equal citizenship to health care would transform the lives of millions. 

Health care has remained one of America’s knottiest challenges. For all that he accomplished in building out US investment in its people through the New Deal, President Franklin D. Roosevelt carefully avoided including health care—he understood just how much power the health-care lobby held, even at that time. President Lyndon Johnson’s Great Society saw the expansion of health care for seniors and the poor through Medicare and Medicaid. And President Barack Obama’s Affordable Care Act stabilized the private insurance model and made critical expansions in Medicaid. But none have been able to achieve that single elusive goal: guaranteed health care for all Americans.

As progressives cast about for explanations for the past and ways forward for the future, it’s worth reflecting on the ways that the policies we propose wrap around the question of belonging. Health care offers one place to do just that. By abandoning the two-tier system of citizenship that our health-care system currently upholds, we can ensure that every American belongs.