Guaranteeing access to health care does not help those who can’t afford to purchase it. Consequently, we also must evaluate health care systems according to whether they make health care coverage affordable, restraining the costs not only of insur- ance premiums but also of copayments, deductibles, and other crucial services such as prescription drugs and long-term care. Although the ACA offers some subsidies and tax credits to help people pay their premiums, it still leaves millions with many indeterminate health care bills.

For health care to be affordable, individual costs must reflect individual incomes. Around half of all insured Americans receive their insurance through employers. Typically, employers pay part of the cost for that insurance and de- duct the rest from each employee’s wages. Because low- and high-wage workers have their salaries reduced by the same dollar amount, low-wage workers are effectively hit harder: Paying $3000 per year for health insurance might, for example, force a wealthier worker to scale back his vacation plans but force a poorer worker to put off fixing his roof. For this reason, the U.S. system is considered financially regressive in that poorer people must pay a higher percentage of their income than do wealthier people. In contrast, in countries such as Great Britain and Canada, health coverage is paid for through graduated income taxes. Poorer persons pay a lower percentage of their income for taxes and therefore for health care than do wealthier persons, creating a financially progressive system. Either way—whether through taxes or lowered wages— the nation’s citizens pay all the costs of health care. The only difference is who pays how much.

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