“If you want to know what is going on, look at the taxes”, this is the advice given by Professor Nicholas Bagley from University of Michigan Law School at the dialogue session on the current political context for health in the United States (US), organised by the Global Health Centre on 28 June 2017. The bill that is currently being discussed in the US Senate to repeal and replace Obamacare eliminates in fact all of the taxes introduced by the Affordable Care Act. This is why Professor Bagley considers it a “tax-cut bill, masked as a healthcare bill”.
The current debate in the US builds on a historical development of the US healthcare system linking health insurance to employment. Within the American political context, health is not understood as a fundamental human right. Professor Bagley underlined that the American Constitution protects negative rights – requiring others to abstain from interfering with a person’s actions – but does not really include positive rights in terms of obligations to provide a good or a service. Furthermore, the racial situation might have negatively influenced social solidarity, which is the basis for building sustainable universal insurance schemes.
Obamacare marked an effort to redress this situation and allowed more than 20 million people to gain health coverage. This is why, in spite of the Republican majority in the US Congress and Senate, repealing Obamacare might prove difficult. The political consequences of taking insurance away from such a large group of people are in fact unknown, as the situation is unprecedented in the world.
Regarding the health consequences of replacing the Affordable Care Act, it is clear for instance that the new bill would have a disproportionate effect on women, as coverage of maternity and preventive services would be at risk. Professor Bagley nevertheless pointed out that, although health insurance has an impact on health, other factors such as education, wealth, and sanitation cannot be forgotten. The debate in the US has, however, a limited downstream focus, without taking into account the broader social and economic determinants of health. Furthermore, some actors remain on the sidelines. According to Professor Bagley, the industry does not support the bill and could potentially stop it, but is not engaging in this sense.
The question remains to know whether the debate can be broadened and whether a wider group of stakeholders will engage in the discussion. Lessons learnt and experiences from other countries could provide new insights and reinforce the link between health and human rights within the US context. Only history will tell if and how these changes will happen.