A few years ago, a student from my public health history course asked why her mother could not afford insulin without insurance, despite full -time employment. I told him what I came to believe: the American health system was deliberately built in this way.
People often hear that health care in America is dysfunctional – too expensive, too complex and too inequitable. But the dysfunction implies a failure. What if the real problem is that the system works exactly as it has been designed? Understanding this heritage is essential to explain not only why the reform has failed several times, but why the change remains so difficult.
I am a Public health historian With research experience on access to oral health and disparities in health care in the deep south. My work focuses on how historical political choices continue to shape the systems on which we are counting today.
By tracing the roots of today’s system and all its problems, it is easier to understand why American health care is like it and what it will take to reform it in a system that provides high quality affordable care for all. Only confronting how profit, policy and damage have shaped the current system that Americans can imagine and demand something different.
Decades of compromise
My research and those of many others show that today’s high costs, deep inequalities and fragmented care are predictable characteristics developed from decades of political choice This priority profit on people, rooted racial and regional hierarchies and treated health care as a commodity rather than a public good.
During the last century, American health care did not develop from a shared vision of universal care, but from compromise prioritization of private markets,, Protected racial hierarchiesAnd Individual responsibility for collective well-being.
Employer -based insurance emerged in the 1940snot by a commitment to the health of workers but from a Reinforcement of tax policy During the salary in wartime, the gules. The federal government has enabled employers to provide health benefits in tax franchise, to arouse coverage while avoiding nationalized care. This decision Access to health related to employment statusA structure that is still dominant today. On the other hand, Many other countries with insurance pair provided by the employer with robust public options, Ensure that access is not only linked to a job.
In 1965, Medicare and Medicaid programs widely widened public health infrastructure. Unfortunately, they also strengthened and deepened existing inequalities. Medicare, a program administered by the federal government for people over 64, mainly benefited the richer Americans who had access to stable and formal insurance and the employer during their years of work. Medicaid, Designed by Congress as a joint program of the federal stateis addressed to the poor, including many disabled people. The combination of federal and state surveillance resulted in 50 different programs with Eligibility, coverage and widely variable quality.
South legislators, in particular, fought for this decentralization. Fearing the federal surveillance of public health expenses and the application of civil rights, they sought to maintain control on whom has received services. Historians have shown that these efforts were mainly designed to restrict access to benefits Racial lines during the Jim Crow period time.
Swollen bureaucracies, “crawling socialism”
Today, this inheritance is painfully visible.
Declares who chose not to Develop Medicaid under the affordable care law are largely located in the south and include several with large black populations. Nearly 1 non -insured black adults are not assured because they fall into the coverage gap – Impossible to access affordable health insurance – They win too much to qualify for Medicaid, but not enough to receive subsidies thanks to the market of the Act respecting affordable care.
The architecture of the system also discourages care for prevention. Because the scope of Medicaid is limited and inconsistent, Preventive care projections,, Dental cleaningAnd Management of chronic diseases often fall through the meshes of the net. This leads to more expensive care and a later stage that include hospitals and patients more.
Meanwhile, cultural attitudes concerning concepts such as “robust individualism” and “freedom of choice” have long been deployed for Resist public solutions. In post-war decades, while European nations Building national health care systemsThe United States has strengthened a market-oriented approach.
Systems financed by the State were increasingly described by American politicians and the leaders of industry as threats to individual freedom – often rejected as “socialized medicine“Or signs of crawling socialism. In 1961, for example, Ronald Reagan recorded a 10 -minute LP entitled “Ronald Reagan speaks against socialized medicine“, Which was distributed by the American Medical Association as part of a national effort to block Medicare.
Health system administration bloated complexity From the 1960s, motivated by the rise of medical programs managed by the State, private insurers and increasingly fragmented billing systems. Patients had to navigate opaque billing codes, networks and formsWhile trying to treat, manage and prevent disease. In my opinion, and that of other researchers, it is not accidental but rather a form of profitable confusion integrated into the system for insurers and intermediaries.
The cuts offered by President Donald Trump would reduce Medicaid spending by around $ 700 billion.
Roofing gaps, chronic divestment
Even well -intentioned reforms have been built at the top of this structure. The affordable care law, adopted in 2010, has expanded access to health insurance but has preserved many underlying inequalities in the system. And by subsidizing private insurers rather than Create a public optionThe law has strengthened the central role of private companies in the health system.
The public option – an insurance plan managed by the government intended to compete with private insurers and to extend the coverage – was finally withdrawn from the affordable care law during negotiations due to The political opposition of the Republicans and Moderate Democrats.
When the United States Supreme Court made it optional in 2012 so that states offer Expanded coverage of Medicaid To adults with low income winning up to 138% of the level of federal poverty, it amplified the very inequalities that the ACA sought to reduce.
These decisions have consequences. In states like Alabama, around 220,000 adults remain uninsured due to the Medicaid gap Highlight the continuous impact of the state’s refusal to extend Medicaid.
In addition, rural Hospitals have closedpatients give up careand whole counties Lack of ob / gyns or dentists. And when people get care – especially in states where many are not insured – they can raise the medical debt that can upset their lives.
All this is aggravated by Chronic divestment in public health. Federal funding for emergency preparation has decreased for years and local health services are sub-financial and under-effective.
The Covid -19 pandemic revealed how fragile the infrastructure is – in particular in low -income and rural communitiesOr Outdated clinics,, delayed tests,, Limited hospital capacityAnd higher mortality rate exposed the deadly consequences of negligence.
One system by design
The change is difficult not because the reformers have not tried before, but because the system serves the very interests that it was designed to serve. Insurers take advantage of the dark – networks that change, forms that confuse, billing codes that few can decipher. The providers take advantage of an act model which rewards the quantity on quality, the procedure on prevention. Politicians collect the contributions of the campaign and avoid blame by delegation, dissemination and plausible denial.
It is not an accidental dysfunction network. It is a system that transforms complexity into capital, bureaucracy into barriers.
Patients – Especially the uninsured and under-supported – are left to make impossible choices: delay treatment or take debt, ration drugs or skip exams, trust the health system or do without it. Meanwhile, I believe that the rhetoric of choice and freedom disguises how limited the options of most people are.
Other countries show us that alternatives are possible. Systems in Germany, France and Canada varies considerably in structureBut all of them hierans universal access and transparency.
Understanding what the American health system is designed to do – rather than assuming that it unintentionally fails – is a necessary first step towards taking significant changes into account.
Zachary W. Schulz is a lecturer in history at the University of Auburn.