The slogan “healthcare for all” typically stands as a proxy claim for “health insurance for all.” Given the Trump Administration’s recurrent attempts to decrease the effectiveness of President Obama’s comprehensive health insurance regulation reform law, the Affordable Care Act, it’s understandable that health insurance would be a major focus of those concerned with reforming the health care system. Millions of Americans remain uninsured and/or unable to pay for the health services they need, so continued efforts to reform our health insurance system remain vital.
It’s important to make clear that nothing in the following post is an attempt to undermine or devalue the important work being done by those seeking to provide better, more affordable health coverage for all Americans. We need better health coverage for all. Rather, my point here is that health insurance for all is not enough for us to achieve health care for all.
In other words, health insurance reform is necessary but not sufficient.
This distinction between health insurance and health care was made nicely in Zack Buck’s Harvard Law School Health Law Workshop presentation “The Price of Universality: Sustainable Access and the Twilight of the ACA.”
Health insurance—for those who can afford it—provides assistance to help people pay for health care, but for those Americans who distrust health care providers, having the funds to pay for health care probably won’t be enough to get them to seek out medical services. For those for whom the health care system has worked well, this kind of distrust may seem like a foreign idea. But from the Tuskegee syphilis study, to compulsory sterilization of people of color, inmates, the poor, and the mentally ill (happening as recently as 2010), to disparate health outcomes and quality of service along racial lines, the way healthcare has been meted out in the United States has created good reason for many populations within its borders to be wary.
This problem is at least two-fold.
First, evidence suggests that discrimination and racial bias from providers still plays a role in the inferior health outcomes for certain racial groups, notably African Americans. Especially given what we learning about implicit bias, addressing racism on the part of providers is a big, difficult, and important challenge.
But despite the many imperfections of our current health care system, it is still often the case that groups like African Americans and others who exhibit distrust and avoidance of health care providers would be better off if they were receiving care than if they weren’t.
Thus, in addition to addressing issues of racism and disparate quality of care, public health institutions also need to work on building trust with the communities they are tasked to serve, but for whom their bad past (and sometimes present) actions have led to distrust and a severing of relationship.
Building this kind of trust is a tricky task, because the justified distrust of communities that have gotten the short end of the stick when it comes to quality healthcare may rightfully be suspicious of attempts to rebuild trust. But the difficulty of the task isn’t an excuse to avoid trying.
Doubling down on simply stating one’s trustworthiness is likely to be ineffective, but there are reasons to think that relationship-oriented strategies like acknowledging past mistakes, seeking to right past wrongs, and training a more diverse group of health care providers may be more effective strategies, along with seeking to help providers close the gap in terms of the quality of care they provide to those in different groups.
Mark Satta is a 2018-2019 Petrie-Flom Center Student Fellow.