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Now that the zombie American Health Care Act seems to be six feet under again — for the time being — we can get back to policy discussions about the real effects of health reform.

In a new book, An American Sickness, journalist Elisabeth Rosenthal laments medicine’s quick transformation from a patient care system to a multitrillion-dollar business — one perverse incentive at a time.

One major failing: Even after the Affordable Care Act, there’s an uninsured population in the US that’s nearly as big as the population of Canada.

Since 2013, the number of uninsured Americans is down from 18 percent in 2013 to 11.9 percent in 2016 — but there are still nearly 30 million people living in America without health insurance.

“When you look at it from the perspective of much of rest of the developed world — to have 10 percent of population without good access to health care shows how far we still have to go,” said Rosenthal, a doctor, former New York Times writer, and now the editor in chief of the nonprofit Kaiser Health News. (Return Monday for a Vox Q&A with her about the absurdity of the health system and its out-of-control costs.)

The size of the uninsured group is well-known, but less clear is what this group looks like. A new series in the Lancet on health inequality paints a pretty good picture. People who go without insurance in America are not refusing coverage for ideological reasons: They simply can’t afford to pay.

Most uninsured Americans have yearly incomes that are near or below the poverty line ($11, 770 for an individual in 2016). “Among non-elderly adults, 7.6% of the non-poor were uninsured in 2015 compared with 25.2% of the poor and 24.1% of the near-poor,” the Lancet reports. In other words, the poor and near poor were more than three times more likely to be uninsured than their higher-income counterparts.

And while the ACA’s Medicaid expansion was meant to bring health care to people in poverty, 19 states opted out of the program, and Medicaid enrollees face barriers to access even in expansion states.

The other group that’s less likely to be insured are people of color, according to the Lancet. “With respect to racial disparities, in 2015 the uninsurance rate among adults aged 18–64 years remained far higher for Hispanics (27.7%) and non-Hispanic blacks (14.4%) than for non-Hispanic whites (8.7%), showing that long-standing racial and ethnic inequalities have been attenuated but by no means eliminated.”

The disparities in access to care are wider in the US than in other developed countries. “Before the 2010 passage of the ACA, which progressively expanded health insurance coverage, 39% of Americans with below-average income reported not seeing a doctor for a medical problem because of cost, compared with 7% of low-income Canadians and 1% of those in the UK,” the Lancet reads. They're also linked to a big mortality gap: The richest 1 percent in America live up to 15 years longer than the poorest 1 percent.

The Lancet researchers don’t think the kind of market-based reforms the GOP is pushing are the solution to the problem here, and point out they'll make inequality worse. Instead, they’re siding with a certain American champion of universal health care: “A single-payer, Medicare-for-all reform — championed by Senator Bernie Sanders during his upstart presidential campaign, as well as by many physicians and the nation's largest nurses union — would, in our view, best address health-care inequalities.” (Sanders makes an appearance in the Lancet, with an editorial.)

Rosenthal is more of an incrementalist. She doesn't think blowing up the system is realistic. "This system progressively got built one action at a time, the perversion of one incentive at a time," she said. To bring the US more in line with other wealthy countries — in terms of both cost and access — she thinks we need to unravel those perverse incentives, one small step at a time.

Chart of the Day

Lancet

Here's what the uninsurance rates in the US look like by poverty status for people under 65. Two things to notice: This population has gotten smaller over the years, but it's still huge. And you can see that poorer Americans are much more likely to be uninsured than their wealthier counterparts.

Kliff's Notes

With research help from Caitlin Davis

• "Florida lawmakers want to require Medicaid enrollees to work": “The federal government has historically spurned work requirements, but the Trump administration signaled last month that it is open to them. Kentucky, Arizona, and Arkansas are other red states looking to take up the administration on that offer. The idea has a lot of problems, as Dylan Matthews recently explained. The majority of Medicaid recipients are elderly, blind or disabled, or children and pregnant women. Requiring them to work doesn’t make much sense. Of the able-bodied adults enrolled in the program, most of them already work. Those who aren't working tend to be sick, caring for a family member, in school, or unable to find work. Even conservative experts are dubious about the policy’s merits.” —Dylan Scott, Vox
• "The GOP’s first step on health care is admitting it has a problem": “In the current political climate, the reality is that there is no way to craft a grand compromise on health care without radically altering the political calculus by changing the terms of the policy debate. Having invested so much time, energy and political capital in their current positions, all factions are so dug in that the only way to shake them loose is by putting on the table ideas that are so bold and so tempting that they are willing to consider giving up something to get them.” —Steven Pearlstein, Washington Post
• "Meadows: Freedom Caucus would back bill that got rid of 3 ObamaCare regs": “The caucus has withheld its support from the GOP's ObamaCare repeal bill last month, saying it does nothing to drive down insurance premiums. But in an effort to sway the caucus, Vice President Pence offered this week to get rid of three regulations: essential health benefits, which mandate what services insurers must cover; community rating, which says insurers can't charge sick people more for insurance; and guaranteed issue, which says insurers must cover people with pre-existing conditions.” —Jessie Hellmann, the Hill

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