Divided over healthcare

Thomas Sajan Titto Idicula | Updated on March 09, 2018

Americans spend the highest on healthcare, but lag behind many countries in health indicators.

Seldom does a highbrow debate keep the US on the boil for over 1000 days. The Patient Protection and Affordable Care Act — popularly called Obamacare — had done just that.

Ever since being signed into law in March 2010, passionate arguments for and against Obamacare remain alive and kicking. The business tycoon and presidential aspirant, Donald Trump, used even the recent Boston Marathon bombings to voice scepticism, by asking whether the lone surviving hospitalised culprit was also ‘eligible’ for Obamacare.

Queries and worries are now at their peak, as many key provisions of the 974-page Act are scheduled to be phased in by January 2014. A book helping Americans understand the intricacies of the new law, Obamacare Survival Guide, is in the top of The New York Times best sellers list.


Despite being efficient, cutting-edge and innovative, the present insurance-based healthcare system in the US is highly inaccessible and exclusionary. This explains why the US, even while having the world’s highest expenditure per capita on healthcare (equivalent to 17.9 per cent of its GDP), lags behind most European countries in health indicators.

Obamacare is basically an ‘egalitarian cap’ on what insurance companies and individuals can do in the healthcare market. It requires all US citizens to obtain private health insurance, while placing tighter control on insurance firms. The government will help low income citizens to buy insurance at an affordable rate by granting subsidies. These, in effect, will substantially increase federal presence in the national healthcare system.

The rationale behind the current government intervention was originally pointed out by the Nobel Prize-winning economist Kenneth Arrow in an influential 1963 paper Uncertainty and the Welfare Economics of Medical Care. His basic point can be summarised in the words of Paul Krugman, a staunch Obamacare supporter: “Healthcare can’t be marketed like bread or TVs”.

This is because, unlike other goods and services, no one can really predict when health expenditures will incur. Whenever the need arises, as in the instance of a heart attack, there is no room for a standard market situation based on consumer choice here.


The real-life incident of an Indian immigrant might aptly illustrate what can happen to the uninsured in the private, for-profit US healthcare system as it exists today.

Sanjay (original name changed) was just another immigrant who arrived in the US on a green card. The visa in no way guaranteed a good job, leave alone being able to afford expensive health insurance. He eventually ended up as a shift worker who opted – or rather, was forced – to become one among the 45 million uninsured US residents.

Two years later, when Sanjay was struck down with chest pain, he was admitted to a university hospital and attended by one of the country’s most renowned cardiologists. He was also surprised to see the profound efficacy of American health care system, when he underwent a bypass surgery in a matter of two days at no direct cost to himself.

That, however, was just one side of the story. Once discharged after the acute care, he was on his own, deprived of any privilege to make an appointment with the cardiologist or even a general physician. For the uninsured, the American government’s healthcare responsibility is limited to taking care of acute emergencies.

It is to people like Sanjay that Obamacare is going to make a difference. But what it is attempting is not a government takeover of healthcare, but regulating the health insurance market. The private healthcare system as of today will remain, but under a strong federal umbrella.

The proposed model is actually quite similar to the existing health care system in a country on the other side of the Atlantic: Switzerland. The Swiss model obliges every citizen to buy insurance available in the private market.

The government supports low-income families who are unable to buy insurance, while forcing companies to provide a profit-free basic insurance. Insurance companies are also obliged to provide coverage for the same price to Swiss citizens of all ages, regardless of their pre-existing diseases.


Most media, physician groups and a large majority of insured Americans consider Obamacare as a fundamental threat to what makes them ‘more’ modern – the free market. Conservative writer Ann Coulter has commented that Obama would turn America into a “Pathetic Western European Country”.

Europeans are obviously baffled by such a response. As French filmmaker Vincent Galiano sarcastically puts it: With Obamacare, the US “at least becomes a modern nation”.

Interestingly enough, President Obama has expressed sympathy with the European position. “Can America, the wealthiest nation on earth, do what every other advanced nation does, which is to make sure that every person here get adequate health care coverage, whether they're young or old and whether they are rich or poor?”, to quote him.

Only time will tell whether Obama will succeed in ‘modernising’ the American health system, and emerge as a legendary figure in the process. One thing is certain; never before in recent history has a US President braved enough to check the reckless profiteering of an industry as powerful as insurance.

(Sajan is a social anthropologist at University of Bergen, Norway. Idicula is a consultant neurologist and researcher at the Norwegian University of Science and Technology, Trondheim, Norway.)

Published on May 17, 2013

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