The large demand for health insurance that overwhelmed the federal as well as many state exchanges comes from the large number of people in the U.S. who have no health insurance. About 15%, or more than 45 million people, had no health insurance for all of last year according the newly released report on Income, Poverty, and Health Insurance in 2012. Oppressed nationalities (African Americans, Asian Americans, Chicanos, Latinos and Native Americans) had even higher rates of going without health insurance, with the rate topping 30% for Chicanos and other Latinos.

The main reason for so many people going without health insurance is that businesses have been cutting health insurance benefits for their workers. In addition, the restructuring of the labor market to replace full-time, permanent jobs with more and more part-time and temporary jobs that intensified during the last recession also means fewer workers have health insurance. While young people have the highest rates of lacking health insurance, the biggest drop over the years have been among workers aged 25 to 64.

While the ACA promises to cover millions of Americans who lack health insurance, mainly through the expansion of Medicaid, which will be available in many, but not all, states to all low-income people. But millions more, including the 11 million undocumented in this country, will still not have health insurance even after the ACA is fully up and running.

The fundamental problem is that it is not profitable to insure everyone, and that for-profit health insurance spends about ten times as much for administration, profits for share-holders, huge salaries for CEOs, than government health insurance does. With the ACA based on forcing individuals to buy health insurance from private insurers through a combination of penalties (individual mandate) and subsidies, it actually expands this expensive and wasteful part of U.S. healthcare.

The example of Massachusetts, which pioneered a very similar plan to the ACA, shows both what this ACA can and can’t do. Massachusetts has the lowest rate of people without health insurance, at about 3%. On the other hand, Massachusetts is the most costly in terms of total health care spending, coming at 36% above the national average.

To both cover all Americans and lower costs, what is really needed is a single federal government health insurance, similar to Medicare, but available to everyone, also known as a single-payer system.

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On June 28 the U.S. Supreme Court upheld most of the 2010 Affordable Care Act or ACA. In particular, the Court upheld the “individual mandate” that requires people with incomes above the poverty line to buy private health insurance. While the Court did not accept the government's argument that the mandate itself was constitutional, a slim majority (5-4) said that the fine for not buying insurance was like a tax and therefore was constitutional.

This ruling upholds the status quo in U.S. health care – a system based on private, for-profit health insurance, hospitals and drug companies. While rejecting the right-wing and Republican arguments against government health care, it upholds the Obama administration’s and the Democrats’ strategy of using government powers to aid big business, from Wall Street to health care corporations. This strategy will not provide universal coverage, nor will it bring down the cost of health care.

The Supreme Court struck down the part of the law that forces state governments to expand the Medicaid programs (health care for low income individuals) with federal help. If this ruling ends up blocking the expansion of Medicaid, some two-thirds of the uninsured, or more than 30 million people, will end up without any health insurance even after this ‘health care reform’ takes place.

Even if the Medicaid expansion were to come about, Medicaid is a second-rate government insurance. Because it pays as little as half what Medicare (government health care for the elderly and disabled) pays, many doctors don’t accept Medicaid patients and some hospitals even have separate clinics for Medicaid patients. People with Medicaid often have to rely on county hospitals and wait months or even more than a year for tests and treatment.

The Affordable Care Act also doesn’t bring down the cost of health care. Even though the U.S. spends the most on health care of any country, and 50% to 100% more than other capitalist countries like Britain, Canada, Germany, or Japan, our outcomes in terms of how long we live and how healthy our babies are worse than these countries. The main reason is that the U.S. is the only capitalist country with for-profit, private health insurance, which can skim off 25% or more of the health care dollar for profits and huge executive salaries and which only wants to cover those who can pay and aren’t sick, leaving millions without any health insurance.

Only a single-payer, government health insurance can eliminate the waste of private, for-profit insurance. The United States already has a form of this, which is Medicare. Medicare’s administrative costs take less than 2% of their premiums while 98% goes to pay for medical care. Medicare already covers the most expensive patients – the elderly and disabled – and it would be relatively simple to expand Medicare to cover the entire population, which would save up to $400 billion a year in health care costs. In Canada, which has single-payer government health insurance, medical drugs can cost as little as half of what they cost here in the U.S., because the Canadian government bargains with the drug companies for lower prices (something that drug companies blocked here in the United States).

The problem with single-payer government health insurance is not practicality, it is politics. The for-profit health insurance companies are part of Wall Street, and for-profit hospitals and drug companies are big business. With Wall Street and big business in control of both the Democratic and Republican parties at the national level, the best way forward at this time may be to fight for single-payer health care at a state level. Fight Back! encourages all of its readers to support efforts to win single-payer health care health insurance in their state.

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In the U.S. Census report on health insurance coverage in 2008 (which also covers income and poverty), the percentage of people with private health insurance dropped again, from 67.5% to 66.7%. This is the eighth year in a row that this percentage has fallen. 20 years ago more than 75% of the population had private health insurance, but more and more businesses have cut their health benefits and individual policies have become too expensive. Last year, more than 15% of the population, or more than 46 million people had no health insurance, private or public, for the entire year.

The health insurance situation is even worse for African Americans, Latinos and other oppressed nationalities. Only 52% of African Americans have private health insurance as compared to 75% of whites. More than 30% of Latinos had no health insurance at all, as compared to less than 11% of whites. This lack of health insurance is one of the factors contributing to poorer health and earlier deaths for oppressed nationalities.

But lack of health insurance is just part of the problem. Health insurance companies can increase their profits in two ways. They can use their size to bargain with doctors and hospitals for reduced rates. They can also not pay for treatment by excluding 'preexisting conditions' or certain treatments or drugs. This has led to a growing problem of 'underinsurance' where more and more people with private health insurance are hit with staggering medical bills, while others cannot get insurance at all because they are sick. Right now most of the people who declare bankruptcy because of their medical bills actually have health insurance!

This decline in private health insurance coverage is also a growing problem for the big health insurance corporations, which are losing their customers. But this could change with the health care 'reform' bill in the Senate, which would force everyone to buy private health insurance or face a government fine. The government would subsidize lower-income households that can’t afford to buy private health insurance, but this would still leave many working families with a choice between health insurance that they can't afford and going without insurance and paying a fine. The Wall Street Journal said that the biggest beneficiaries of health care reform could be the health insurance and drug companies.

Many liberals and Democrats in Congress have been pushing for a 'public option,' or a government-run health insurance company that would compete with private insurance companies. The public option was first proposed as a huge program that would take half the insurance market and use its size to force down costs and offer lower premiums. But the public option plan that is actually in Congress today is a shadow of the original plan, with so many restrictions that it would not be able to be big enough to offer real savings.

The other problem with the current bills in Congress is that they pit working people against each other. In order to get the private insurance companies to accept people who are already sick, it will force others to buy insurance that they can't really afford. To pay for the subsidies for lower-income working people, there will be future cuts in Medicare spending. The health reform bill also opens the door for new taxes on employer health insurance plans and explicitly excludes the undocumented.

What working people really need is a government run, single-payer health care system. There is a model for this: Medicare, which covers people over 65 years of age and spends only 2% of total revenues on administration. In contrast, private health insurance companies that run 'Medicare Advantage' programs spend almost 17% of revenues on administration and profits. Medicare also benefits from its huge size, which allows it to reimburse hospitals and doctors at lower rates. A single-payer health insurance would have the same ability as Medicare to keep costs low.

Our neighbor to the north, Canada, has a government single-payer health care program, also called Medicare. In Canada the government health insurance bargains with drug companies to lower their prices, thus the well-know fact that prescription drugs are cheaper in Canada. But here in the United States, lobbying by the drug companies has led to a ban on the government bargaining for lower drug costs. It is no wonder that we have high health care costs, where 15.8% of our economy is devoted to health care, while in Canada, only 10% is. But Canadians manage to live longer and have a lower death rate for infants, while maintaining a choice of doctors. Thousands of doctors and now the country’s largest trade union federation have endorsed a single-payer insurance plan. The time is now to fight for health care reform for working people, not for profit-making insurance companies. The best way to do this is a single-payer plan.

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