Shubh Thakkar

Introduction

The United States of America is known globally for the exorbitantly high healthcare costs
that individual citizens have to shoulder. These expenses are a result of privatization in
America’s health insurance industry: health insurance is dominated by the private sector with very little government assistance or intervention. The United States’ privatized health insurance structure is unique among countries with developed economies. Unlike the United States, most countries with developed economies offer publicly-funded universal health insurance that all citizens are entitled to. According to the Public Health Advocate, a periodical published by the University of California, Berkeley, “…the United States remains the only industrialized country in the world that fails to provide universal healthcare for all citizens” (2016).

Universal health insurance creates a structure of healthcare services that are publicly financed and widely accessible, keeping healthcare costs low for the individual citizen. Because the United States’ privatized health insurance model often leads to extremely high prices and varying degrees of accessibility for essential healthcare services, policymakers have recently considered the efficacy of implementing a publicly-funded universal health insurance model to improve accessibility.

The country of Denmark is commonly used as an example to demonstrate the success of universal health insurance. In Denmark, healthcare services are publicly funded and free to all Danish citizens. The Danish government pays for all medical assistance, primary care appointments, and hospital stays. In addition, Denmark also subsidizes the cost of prescription medication so that citizens do not have to pay the full cost (Osborn et al. 2020). The Danish state’s universal health insurance model effectively decreases the healthcare expenses that an individual citizen shoulders. This raises an important question: can a universal health insurance model (such as the Danish example) be plausibly applied to the United States to improve access to healthcare services?

Application of Game Theory

With the assumption that American citizens want to maximize their accessibility to
healthcare services in mind, I argue that a coordination problem and Schelling coordination grid can be used to model the privatized health insurance model of the United States. The plight of the American health insurance industry is essentially a coordination problem with ranked equilibria. Americans of all classes prefer some form of health insurance coverage as opposed to not being covered, and they would all benefit from a universal health insurance model. However, they are trapped by relying on privatized health care, which represents the inferior equilibrium/convention.

Gerry Mackie (1996) utilizes a similar application of the ranked-equilibrium coordination problem to address female genital mutilation (FGM) in Africa. Under the assumption that men and women both would prefer to marry rather than stay single to successfully raise their biological children, Mackie argues that the practice of FGM is the inferior equilibrium of a ranked-equilibrium coordination problem between men and women. Women want to marry a partner to ensure that their children are materially supported. Men want to marry a partner to be confident that he is the biological father of his children: he would be assured of his children’s paternity if his partner is faithful to him and does not engage in relations with anybody else.

Both men and women are better off without the practice of FGM, as men would be able to benefit from their partner’s increased longevity, and women would not have to experience an extremely painful procedure. However, women continue to undergo the practice because they falsely believe that it will improve their marriage prospects. Men in turn believe that a woman who has undergone mutilation will be a faithful monogamous partner, which ensures the man’s confidence in his child’s paternity. This harmful convention has become reinforced over time, leading to society being trapped at the inferior equilibrium point.

Argument

Based on of this coordination problem, it is evident that the United States needs to find an
effective trajectory from the inferior equilibrium (privatized care) to the superior equilibrium
(universal, publicly funded health insurance). Applying a universal health insurance framework such as the one used in Denmark can provide a pathway to move the U.S. toward the superior equilibrium. In standard form, this argument consists of the following premises and conclusion:

• Premise 1: Poor health outcomes and access to healthcare services are concerns for
citizens in both the U.S. and Denmark, but the current U.S. healthcare system does not
sufficiently address these concerns for American citizens.
• Premise 2: If implementing a universal health insurance model was successful in ensuring
access to healthcare services for every citizen in Denmark, then the Danish healthcare
model could be implemented to address these issues in the U.S.
• Premise 3: Denmark’s universal health insurance model is successful in creating
equitable access to health care services for every Danish citizen.
• Conclusion: Denmark’s universal health insurance model is a plausible framework to
apply to the United States.

Evidence

Premise 1

Health insurance continues to be an enormous obstacle to Americans’ access to health
care services. Access to healthcare services in the United States varies considerably based on what is covered under one’s insurance plan. A medication or procedure that is covered under one individual’s health insurance policy may not necessarily be covered under a different individual’s policy. The more services that a private health insurance policy covers, the more expensive it will be. This also leads to different groups of people paying different costs for the same care, and some people are not able to afford certain procedures or medications due to the cost associated with them.

According to a survey performed by the Commonwealth Fund (2022), 9% of Americans have no healthcare insurance coverage at all. 43% of Americans are underinsured: their health insurance policies do not adequately cover their healthcare expenses. 46% of Americans surveyed reported skipping or delaying health care that they needed due to the financial burden associated with seeking that care. In addition to this, 42% of Americans reported having difficulty paying off medical bills. Racial minorities are also much less likely to have health insurance coverage than white people.

Premise 2

If implementing a universal health insurance model in Denmark effectively worked to
reduce healthcare expenses shouldered by individual citizens and improve access to healthcare services, the same model would be effective in improving healthcare accessibility in the United States. Denmark and the U.S. are very similar in several vital areas. Both nations are highly developed free-market economies with high living standards. Both countries are in the top ten of the United Nations Human Development Index, and both countries also have similar unemployment rates (“Human Development Insights by Country,” 2022). In addition, both the U.S. and Denmark have similar political and economic priorities: both countries are dedicated to the development of high-tech sectors in their economies, and both attribute a lot of importance to freedom of speech, expression, and religion.

Premise 3

It is evident that Denmark’s universal health insurance model has been very successful in
reducing healthcare-related financial burdens on Danish citizens. Danish citizens can depend on public health insurance for the vast majority of their routine and emergency healthcare needs. Universal, taxpayer-funded health insurance in Denmark covers hospital stays, visits to a primary care physician, specialist visits, emergency care, and home care with no copays or deductibles. On the other hand, Americans must pay heavy premiums, copays, and deductibles to access even the most basic of healthcare services.

In addition to this, one can look at healthcare spending in each country, which is often
measured in current health expenditures. This metric expresses “the share of spending on health in each country relative to the size of its economy” and includes “expenditures corresponding to the final consumption of healthcare goods and services,” according to the CIA World Factbook (2020). Relative to other countries with well-established, developed economies, the U.S. spends a lot more on healthcare than any other developed nation, but it is the only developed nation that does not guarantee universal health insurance coverage. America’s lack of universal health insurance forces its citizens to spend exorbitantly high amounts on private insurance to receive healthcare services, leading to the current health expenditures figure to increase exponentially in response.

According to the CIA World Factbook, healthcare spending accounts for approximately
18.8% of the American GDP. On the other hand, Denmark’s healthcare spending accounts for only 10.5% of its GDP (2020). According to statistics from the World Bank (2022), current health expenditures per capita in Denmark are about $6,003 USD, whereas in the United States, current health expenditures per capita lie at about $10,921. Denmark’s universal health insurance model has led to lower healthcare spending, making it much easier to afford and access healthcare. On the other hand, the U.S.’s privatized health insurance industry has done the exact opposite.

Cultural Counterargument

It is commonly argued that implementing a universal health insurance system in the
United States is not feasible because of the difference between American and Danish societal values. Danish society attributes a lot of value to social equity, and from a public policy perspective, this translates into a strong welfare state where everyone reaps equal benefits. In contrast, the United States is a hierarchical society that values individual efforts and hard work. Because American society is heavily centered on the actions of the individual, there is strong societal opposition to a strong welfare state. This in turn would make it very difficult to gain public support for a universal health insurance system, making it unlikely that publicly funded care would be a plausible model to apply to the United States. In standard form, this counterargument consists of the following premises and conclusion:

• Premise 1: The success of a given policy intervention for a social issue is heavily
dependent on the cultural context that the intervention is utilized in: what works for one
country may not work for another due to different cultural values and what different
cultures prioritize,

• Premise 2: If implementing a universal healthcare model was successful in improving
health outcomes and ensuring access to healthcare services for every citizen in Denmark,
then implementing a scheme similar to the Danish universal healthcare model would be
effective in addressing health concerns in countries with similar cultural values.

• Premise 3: Denmark and the United States do not share many cultural or societal
similarities.

• Conclusion: Denmark’s universal healthcare model would not be a plausible model to
address health concerns in the United States.

Rebuttal

Although there are indeed significant cultural differences between the U.S. and Denmark,
this does not necessarily mean that a universal health insurance framework would not be a plausible model for the U.S. to follow. Almost all public policy interventions to address any social issue will encounter obstacles when attempting to gain public support. Once this obstacle is overcome, a universal health insurance framework would be expected to yield similar benefits and enhance accessibility to health care services.

However, it is important to note that an increasing share of American citizens favor government-funded healthcare insurance schemes. According to a survey performed by the Pew Research Center, 63% of American adults believe that the federal government should be responsible for providing health insurance coverage for all U.S. citizens. Statistics calculated from the same survey state that 30% of all Americans believe government-funded health insurance should be provided through a universal, single-payer program (Jones 2020). Although the U.S. tends to have different cultural values than countries known for their effective universal health insurance models, like Denmark, public support for universal healthcare policies still exist.

There are also countries across the world that attribute importance to different cultural
values and have still successfully implemented government-funded insurance schemes. For example, one can consider Canada, which also has a distinct culture compared to that of Denmark. Canada has a decentralized, universal, publicly funded health system that is administered by the country’s 13 provinces and territories (Tikkanen et al. 2022). Although Canada’s universal health insurance system does have logistical flaws, it is successful when it comes to reducing the cost burden on individual citizens. According to the Canadian Institute for Health Information, Canada’s current health expenditures represent about 12.2% of its GDP, which is much lower than the U.S.’s healthcare spending under a privatized system. Differences in cultural values are an important factor to consider when implementing any sort of policy intervention. However, despite cultural and societal differences, implementing a similar system would likely still be successful in the United States due to widespread public support and the success of universal healthcare systems in other countries.

Normative Ethics and Social Justice

When analyzing the debate around the American health insurance system through a
philosophical lens, it is important to acknowledge the role of normative ethics, which provide a framework for how humans should act in certain situations. Normative ethics attempt to provide a morally correct option for the way one should act, and these ethics operate on a set of assumptions of what is good or bad. Normative ethics are often guided by a sense of social justice: many deem an action that effectively creates equitable access to opportunities, wealth, and resources as morally correct.

The goal of implementing a universal healthcare system is to ensure that all people have access to vital healthcare services, regardless of race, socioeconomic status, or gender. When one uses social justice as a guide to decide what is morally right or wrong, creating a universal health insurance structure would be seen as a morally correct course of action, as it attempts to create equity between social groups. However, to build a truly equitable health insurance system, it is important that the federal and state government, hospital networks, and healthcare providers also focus on historically underserved areas and demographics to correct historical disparities.

Conclusions

American healthcare is dominated by private industry, and this is the result of a failure to
coordinate between social groups. This miscoordination has led to inefficiency and
inaccessibility within American healthcare networks. When America’s health insurance system is modeled by a coordination problem, it is evident that Americans are trapped in an inferior equilibrium, represented by the country’s privatized healthcare system. It is in the best interest of all Americans to move towards a universal, publicly funded health system. Implementing a health insurance model similar to the Danish model may provide a pathway for the United States to move toward that superior equilibrium.

Although there are substantial differences between the United States and Denmark that
need to be accounted for, the United States needs to look toward providing more public funding towards healthcare in order to make healthcare services accessible to all people. The Danish model provides key healthcare funding strategies that can be implemented by American policymakers to maximize efficiency and accessibility.

Works Cited

Canadian Institute for Health Information. (2022). National health expenditure trends. Retrieved April 16, 2023, from https://www.cihi.ca/en/national-health-expenditure-trends

Central Intelligence Agency. (2020). Current Health Expenditures. CIA World Factbook.
Retrieved April 16, 2023, from https://www.cia.gov/the-world-factbook/field/current-
health-expenditure/

Jones, B. (2020, September 30). Increasing share of Americans favor a single government
program to provide health care coverage. Pew Research Center. Retrieved April 16, 2023,
from https://www.pewresearch.org/fact-tank/2020/09/29/increasing-share-of-americans-
favor-a-single-government-program-to-provide-health-care-coverage/

Mackie, G. (1996). Ending footbinding and infibulation: a convention account. American
Sociological Review, 61(6), 999. https://doi.org/10.2307/2096305

Maysonave, A. (2016). Health and Infrastructure in the U.S. and Denmark. Public Health
Advocate. Retrieved April 16, 2023, from https://pha.berkeley.edu/2017/02/27/does- denmark-have-a-better-healthcare-system-than-us/

Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. A. (2020, June 5). Denmark:
International Health Care Profiles. Commonwealth Fund. Retrieved April 16, 2023, from
https://www.commonwealthfund.org/international-health-policy-center/countries/denmark

The State of U.S. Health Insurance in 2022. Commonwealth Fund (2022, September 29).
Retrieved April 16, 2023, from https://www.commonwealthfund.org/publications/issue-
briefs/2022/sep/state-us-health-insurance-2022-biennial-survey

Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. A. (2020, June 5). International Health Care System Profiles: Canada. Commonwealth Fund. Retrieved
April 16, 2023, from https://www.commonwealthfund.org/international-health-policy-
center/countries/canada#ensuring-quality-of-care

United Nations Development Program. (2022). Human Development Insights by Country.
Human Development Reports. Retrieved April 16, 2023, from https://hdr.undp.org/data-
center/country-insights#/ranks

World Bank. (2022). Current health expenditure per capita. Open Data and DataBank. Retrieved April 16, 2023, from https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD