The United States is one of the few remaining developed countries which has yet to implement some form of universal health care. Despite its imperfections, the individual mandate of the Affordable Care Act (ACA) brought the U.S. one small step closer to such an achievement. Republican politicians have steadfastly opposed the ACA, and have promised to repeal the Act since its promulgation. With the inauguration of Donald Trump, the Presidency, House, and Senate are controlled by Republicans, and the threat of ACA repeal is more real now than ever – with repeal promised for Spring 2017. To their credit, Republicans have changed ‘repeal’ to ‘repeal and replace,’ but disunity over what should replace the ACA has left many people concerned about their insurance coverage. Naturally, others have doubted whether a viable replacement will materialize at all.
If the ACA is repealed without replacement, things do not look well. The Urban Institute ran the numbers, and predict that the proportion of uninsured people will be greater after repeal than it was before the introduction of the ACA. They estimate that 29.782 million Americans will become uninsured by 2019, for a total of 58.718 million uninsured. Some will suggest that, in terms of the country as a whole, 58.7 million may not seem too bad. After all, if this means that about 21% of the non-elderly U.S. population (274.316 million), or about 18% of the total U.S. population (321.774 million) doesn’t have health insurance, it also means that large majorities (about 79% and 82% respectively) of people do have insurance. Of course, having insurance does not mean a person also has adequate coverage, or that their insurance is not an economic burden, or any number of other critiques which are beyond the scope of my argument. What I really want to get into is that number: 58.7 million.
The problem with thinking about populations in terms of percentages is we have a tendency to forget about the quantities of people we’re actually referring to. The United States is the third-most populous country in the world, being something of an outlier among developed countries, and so in many cases using percentages and proportions no longer makes sense. In other fields, a risk increase from 0.0001 to 0.0005 may be communicated as an increase of 500%, but this percentage statistic is used to hide the extremely small numbers that are actually at stake. In the case of uninsured Americans, percentages can be used to hide extremely large numbers, dismissing them as a minority of people. Because, really: 58,718,000 people is a lot of people. It may as well be an entire country of people. In fact, it’s about an Italy worth of people.
An Italy worth of people? Yes. In 2015 (most recent data), Italy had a population of about 59,798,000. ACA repeal without replacement will result in the equivalent of almost the entire population of Italy losing their health insurance.
Thinking of populations in units of ‘other countries’ is nothing new, if a bit confusing at first. The following image, which has floated around the Internet for quite a while (originating here), illustrates the idea nicely:
The size of the population of Canada is between one-ninth and one-tenth the size of the U.S. population, thus we can easily use Canada as a unit to measure the U.S. population (U.S. pop. ≈ 10 Canadas; the author of the image rounded up). This exercise can seem a bit silly, but it’s also useful because it helps put very large numbers into perspective. Numbers like 321,774,000 and 58,718,000 are beyond the scope of anything most of us experience in our day-to-day lives. Changing the way we approach these numbers can give them some clarity.
In the name of perspective, I found the number of soon-to-be-uninsured and total uninsured people in the United States, estimated by 2019, in units of other developed countries with universal health care systems. These countries have a variety of insurance systems – including single-payer, two-tier, or a strong insurance mandate – suggesting that universal health care can be achieved through many different approaches. Combined, these countries have a population of 466.426 million people.
|To-Be Uninsured||Total Uninsured||Population (2015)|
|1.24 Australias||2.45 Australias||23.969 million|
|3.49 Austrias||6.87 Austrias||8.545 million|
|2.64 Belgiums||5.20 Belgiums||11.299 million|
|0.83 Canadas||1.63 Canadas||35.940 million|
|5.25 Denmarks||10.36 Denmarks||5.669 million|
|5.41 Finlands||10.67 Finlands||5.503 million|
|0.46 Frances||0.91 Frances||64.395 million|
|0.37 Germanys||0.73 Germanys||80.689 million|
|6.35 Irelands||12.53 Irelands||4.688 million|
|0.50 Italys||0.98 Italys||59.798 million|
|1.76 Netherlands||3.47 Netherlands||16.925 million|
|6.58 New Zealands||12.96 New Zealands||4.529 million|
|5.72 Norways||11.27 Norways||5.211 million|
|2.88 Portugals||5.67 Portugals||10.350 million|
|0.65 Spains||1.27 Spains||46.122 million|
|3.05 Swedens||6.00 Swedens||9.779 million|
|3.59 Switzerlands||7.08 Switzerlands||8.299 million|
|0.46 United Kingdoms||0.91 United Kingdoms||64.716 million|
Sweden is a pretty good fit. The number of people estimated to be uninsured in the United States by 2019 is six Swedens (or, six times the population of Sweden).
In many of these countries, the number of uninsured people at any one time is typically only a few thousand, consisting of new residents who haven’t yet been able to sign up for insurance (some jurisdictions have waiting periods, e.g. 3 months). In others, everyone receives some coverage automatically.
This list is not exhaustive; certainly there are other countries with universal health care regimes. These countries were chosen for their political diversity, and because the extent to which they are ‘developed’ or ‘Western’ is not subject to scrutiny. It includes countries which, in their other areas of domestic policy, typically have interventionist policy approaches (such as Sweden and Denmark), means-tested policy approaches (such as Spain and Italy), or somewhere in between (such as UK and France). Even Switzerland, which is relatively conservative and tends to favor state-level governance (canton) over federal-level governance, is represented.
At a time when universal health care is not only a standard feature of developed countries, but increasingly a feature of developing countries, it would appear that the United States is falling behind – probably at the expense of the health of Americans.
Blumberg, Linda J., Matthew Buettgens & John Holahan. 2016. “Implications of partial repeal of the ACA through reconcilliation.” Urban Institute, Health Policy Center.
United Nations. 2015. World Population Prospects: The 2015 Revision, Key Findings and Advance Tables. Department of Economic and Social Affairs, Population Division.