By Marlee Tichenor
The 48th Session of the United Nations Statistical Commission began yesterday in New York City and will continue through Friday, as more than 300 statisticians from 130 UN Member States meet to discuss how to measure progress toward the Sustainable Development Goals. The title of this and the last two sessions – “Better Data, Better Lives” – highlights the central role of quantifiable data about poverty, hunger, health, education, gender equality, water, energy, economic growth, infrastructure, and general inequality reduction to global development efforts in the SDG era.
The third Sustainable Development Goal is to “ensure healthy lives and promote well-being for all at all ages,” and a central goal to ensuring these healthy lives is universal health coverage (UHC). Target 8 of the health SDG defines UHC as “financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” Within the indicator framework for the SDGs, measuring countries’ progress toward universal health coverage is split into UHC’s two core components: coverage of quality health services and protection from financial risk.
The indicator framework document currently being debated at UN48SC is made up of indicators that can be quantifiably measured to track progress on each of the 10 SDGs outlined above. The Inter-Agency and Expert Group on the Sustainable Development Indicators has established a three-tiered system for judging each indicator’s quality. Tier 1 indicators are those that already have data collection systems in place and a “custodian agency” in charge of collecting them. Tier 2 indicators are “conceptually clear, [have] established methodology and standards available, but data are not regularly produced by countries,” and Tier 3 indicators have “no established methodology and standards, or methodology/standards are being developed/tested.” 35% of the indicators in the document as it currently exists are Tier 3 indicators.
One indicator of particular interest to the discussion of universal health coverage here is indicator 3.8.2, which is about defining “financial risk protection.” In November 2016, the indicator expert group met to fine tune the indicator framework, and until that point indicator 3.8.2 was the “number of people covered by health insurance or a public health system per 1000 population.” Many – including the former Director-General of the World Health Organisation, Dr. Gro Harlem Brundtland – asserted that coverage by health insurance was not a measure of financial risk protection, and we would have to create a new way of tracking how health spending can impact families and individuals. In its new formation, indicator 3.8.2 is designated as Tier 3 because we do not currently have the infrastructure in place to track health spending in this way on a global level. Proponents of this change assert, however, that it is only in creating new data ecologies that we can get at a real image of what is happening in global health.
These are important and discordant discussions in the face of the US Congress’ current work to undo the financial protections the Patient Protection and Affordable Care Act sought to put into place. At heart, the ACA’s goal is to protect Americans from ruinously high medical bills and to provide access to affordable health coverage. By bringing health insurers into a public exchange and subsidising health insurance, the federal government sought to reduce financial risk by regulating health insurance practices (i.e., forbidding health insurers from restricting access to those with pre-existing conditions), making health insurance with lower premiums and better coverage more affordable through subsidies, and expanding Medicaid coverage for those in the lower income brackets and living in states that opted in. In the three years since the law has been in effect, health insurers have increasingly opted out of these public insurance exchanges in many states, largely for financial reasons, giving Americans fewer and more expensive options. This has provided conservative politicians the powerful rhetoric of choice to support their goal of repealing and replacing the ACA.
Risk of financial ruin is not necessarily tied to access to health insurance in the American context either, and in 2013 it was estimated that 10 million insured Americans faced medical bills they were unable to pay. There are limits to the ACA that require strengthening the federal government’s efforts to protecting American citizens’ health and financial state, but rather than take steps in that direction, the current House plan to replace it dislodges its regulatory practices, giving health insurers even less incentive to provide affordable, quality health insurance.
As the UN Statistical Commission debates how we can measure progress toward universal health coverage on a global level, citizens must hold their politicians accountable to meet those goals. As data and facts become more explicitly political in the American context, this will likely also require citizen action on promoting and protecting the data that provide a clear view of health care coverage and spending. Let us hope that raucous town hall meetings and other forms of citizen action will help politicians move forward on guarding health and financial security rather than backward.