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The United States has long been derided as the world’s only industrialized country that falls well short of universal health care coverage. The 2010 Patient Protection and Affordable Care Act (ACA, or Affordable Care Act) will close approximately half the existing coverage gap but will leave more than twenty million people still uninsured. Can anything be done for the remaining uninsured that will bring us, finally, to some acceptable form of universal coverage? In particular, can safety-net programs be structured in a way that provides access to care sufficiently to approximate the goals of universal coverage? To better understand this social policy landscape, this chapter undertakes a conceptual analysis of what exactly we mean by “universal,” “coverage,” and “access.” Understanding the policy significance of these terms over a range of meanings might help crystallize social debate and reveal the most achievable path forward. Necessarily, this inquiry is heavily normative, or value laden, but it avoids being excessively philosophical or opinionated by rooting normative analysis in real-world systems that express and operationalize actual social values . Specifically, I gauge the adequacy of coverage or access according to existing insurance systems that are widely considered to be at least minimally acceptable. My normative task is to identify the low-water markings of adequacy, rather than aim for pure equality. Idealistic aims can be useful to motivate improvements, but rarely are they fully achievable. My aim is more modest: to identify the nearest finish line of what might constitute some acceptable form of universal access. If we as a society are about to run out of gas in the drive for a fair and just health care system, knowing the shortest distance to this goal might help us finally push past rather than stall short of the line. Achieving Universal Access through Safety-Net Coverage Chapter 10 217 Mark A. Hall To identify norms for universality, we begin by looking abroad. Then returning to domestic soil, we explore whether acceptable coverage necessarily requires insurance, or instead whether coverage can be accomplished through direct-access safety-net systems. The chapter concludes with analysis of data measuring access to care in model safety-net programs. Universality Universality can be thought of as a percentage, consisting of a numerator and a denominator. The numerator is the easy part. We hope it can be as close as possible to 100 percent. European countries report covering from 98 to 100 percent of their population—which is similar to the 99 percent of people in this country aged sixty-five or older who are insured, thanks to Medicare. Thus, it appears we can agree on the numerator—that about 98–99 percent is close enough to count as “universal,” or at least nearly so. Population Denominator More troubling is the population denominator. This immediately raises the socially divisive issue of immigration. European countries cover legal permanent residents on essentially the same terms as full citizens (Huber et al. 2008). Likewise, the ACA provides subsidies to resident immigrants on the same terms as citizens and requires them, like citizens, to purchase insurance if it is affordable. Legal immigrants are fully eligible and responsible because the basis of social solidarity is not citizenship, per se; instead, it is living in the same community under the same laws and contributing to the same tax base. Inclusion of legal immigrants is especially appropriate in a country such as ours whose population derives so substantially from its history of massive immigration. Noticeably and notoriously excluded from US health reform, however, are undocumented (or “illegal”) immigrants. From a demography point of view, they are part of the US population, but health reform provides them no subsidies and does not require them to purchase coverage. Accordingly, undocumented immigrants are expected to account for roughly a third of people in the United States who will remain uninsured following full implementation of national health insurance reforms. Should this sizeable portion of the community be included in the population denominator used to gauge universality? Views are deeply divided on this difficult question of social justice. According to some philosophers and theologians, social justice should be judged by how we treat the most underprivileged people. Undocumented immigrants are underprivileged by income and by exclusion from the protections inherent in 218 Mark A. Hall citizenship. However, there are passionate objections to extending full social benefits. Reasons include their basic lack of deservedness, xenophobia, fear of economic competition, and a desire to deter more illegal...


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