A Health Care Mirage

How candidates (and reporters) misuse the word “universal”

By now we all know that the Democratic candidates are fighting about whose plan is more universal. Their sparring in Iowa over whose plan is best has the ring of grade schoolers arguing on the playground about who has the better toy, but it also calls into question the vocabulary of the health care debate. Candidate-induced confusion over language disguises details of their plans. It also misleads.

Universal by common definition means all or the whole without exception or limitations. The word universal, along with the words comprehensive, guaranteed, coverage, and mandate have become the lingua franca of the debate, but in they seem to mean whatever the candidates want them to mean. In other countries, universal health care means care available to every citizen as a matter of right and paid for by everyone through a national health insurance system.

In America the candidates are trying to shoehorn that label onto their plans that basically force uninsured folks to sign up for insurance policies sold by private health insurers. The more people who sign up, especially under the threat of wage garnishment as Edwards and Clinton have suggested, the closer their plan is to the ideal of universal. But none of them will be truly universal since they will inevitably include exemptions, and the number of people who sign up will ultimately depend on the generosity of the tax subsidies to pay the premiums and on the penalties to force compliance. Even Massachusetts will not achieve universal coverage—an estimated 20 percent of the uninsured population is exempted from the law requiring everyone to have health coverage.

Yet the candidates continue to toss around the word. Clinton has charged that Obama’s plan “went from universal when I wasn’t there to comprehensive when I was on the same stage. It’s obvious that he doesn’t want to face up to the very position he took because every time he changes his posture on it, he uses different words to describe it.” Indeed, Obama has said, “I have put forth a universal healthcare plan that will do more to cut the cost of healthcare than any other proposal in this race.”

Clinton, too, has played the universal game. Back in January at the beginning of her presidential quest, Clinton told The Chicago Tribune that one of the goals she would be presenting was “health insurance for every child and universal health care for every American.” The Trib didn’t challenge the double talk. Nor did it illuminate similar word spin in a recent story reporting Clinton’s charge that Obama’s health plan would not offer true universal coverage because he would not require all Americans to buy into a plan as she would. The Trib also noted that Obama countered that his proposal offers guaranteed access at lower costs, but the paper didn’t tell its readers what that meant.

The Wall Street Journal has now taken the story to a new level by quoting dueling campaign advisers, each of whom has his own idea of how many people will go uncovered in the “universal” schemes of either Obama or Clinton. Clinton’s camp says 15 million won’t make it under Obama’s insurance tent. Obama’s adviser says 10 million won’t make it under hers. The sideshow over the numbers blurs a fundamental choice the U.S. could make, if the candidates were straighforward about what is universal and what is not: whether as a nation we want to continue a private health insurance system that will inevitably leave some people out or craft a truly universal system like those of other countries.

We offer a modest proposal for journalists. Whenever candidates throw out the term universal, we should remind audiences what universal health care is and is not.

Has America ever needed a media watchdog more than now? Help us by joining CJR today.

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.