by Danielle Ofri
Medical progress tends to move incrementally. We tweak our treatment protocols over time, adapting in response to research and clinical experience. But America’s view of health insurance is currently evolving at a breakneck pace, thanks to the political upheavals wrought be the Affordable Care Act and the current Republican proposal to replace it. We’re witnessing a medical revolution before our very eyes, this time about access to care, not the care itself.
Americans are now actively debating whether access to health care should be a fundamental right for all citizens? And if so, what is the role of government in guaranteeing this?
For most of the last century in the United States, health insurance has been associated with our jobs. Starting with the advent of Blue Cross just after the Great Depression, health insurance was a benefit marketed to groups of workers. When the post-war economy had businesses desperately competing for workers, employer-based insurance became the norm (The IRS solidified this by allowing these plans to be tax-exempt).
Almost no other country went the employer-provided route. Nearly every single developed economy eventually instituted universal health care organized by the government. It’s not that this wasn’t ever considered in the United States. A proposal in the early 1900s to guarantee health insurance for low-income workers was initially supported by the American Medical Association (AMA), which enthusiastically stated that the “…plans are so entirely in line with our own that we want to be of every possible assistance.” Ironically, the plan was denigrated by the American Federation of Labor as being too paternalistic. It was also attacked by life insurance companies because the plan included death and burial benefits, which could siphon off customers for them. Eventually, money won out—the AMA reversed itself when members complained about the low payments to doctors.
Universal healthcare was supported to varying degrees by President Truman and both President Roosevelts but the idea of “socialized medicine” remained toxic in the public discourse. President Johnson managed to pass Medicare (for older Americans) and Medicaid (for low-income Americans) but with ferocious opposition from the AMA. Expanding health care to all Americans, though, was politically impossible.
Eventually, we ended up with our current system—a strange mix of private health insurance for the employed and public health insurance only for the poor and the elderly. This arrangement added an additional layer of stigma to health insurance backed by the federal government—not only did it smack of socialism but it was also perceived as “charity care” for those members of society who didn’t pull their own weight.
The Affordable Care Act (ACA) sought to even things out. It was forced to do so within our privatized health system—the so-called public option, in which the government would devise its own health insurance plan to compete with the private plans, didn’t make it into the final bill. Although universal healthcare wasn’t the explicitly-stated aim, the ACA was premised on the assumption that every American should be able to get health insurance.
Now that the ACA has been around for a few years, the public has come to accept this premise. You could see it in the outrage expressed in town hall meetings as Republicans mucked with the ACA, and rammed through a hastily constructed replacement. Even before the Congressional Budget Office concluded that 23 million Americans would lose insurance within a decade under the new plan, the public could see that the American Health Care Act revoked the guarantee of health care coverage for every American.
Most of the uproar has centered on the issue of pre-existing conditions—not a surprise since this hits home for every voter with a pulse. If you don’t have a pre-existing condition right now, there’s surely someone in your family who does, (or you’re just a few years away from acquiring one yourself). Illness is an equal-opportunity employer.
Insurance companies, by definition, lose money on sick people, so they have every incentive to keep them out of their pool. They can achieve this by rules that disallow pre-existing conditions or by prohibitively high premiums that effectively keep out the folks that cost too much. Insurance companies are not in the business of making sure everyone has access to health care; they are in the business of making money, so they will rightfully do what it takes to keep their business model profitable.
But we Americans had been so accustomed to this way of doing business that we didn’t fully appreciate the injustice of it until the ACA leveled the playing field. Now, no amount of blather from Republicans about high-risk pools picking up the slack will whitewash the fact that discrimination on the basis of disease is unethical and frankly un-American.
Paralleling the evolution of public opinion is that of the medical community. Organized medicine has lined up in uniform opposition to the Republican plan. When medical groups talk about healthcare these days, they acknowledge it as fundamental right.
On the campaign trail, Donald Trump used language that implied the same, promising better healthcare at a lower cost that would include everyone. Although he almost certainly did not realize it, he was promoting an idea of universal healthcare that could only be achieved by a single payer plan.
Now that public is expecting that every American have healthcare coverage—just as every American is entitled to police protection or use of the highway system—it’s clear that the government is the only body that can guarantee this. And the very idea of government-backed universal healthcare is starting to lose its “socialized” taint in public discourse, as the emphasis shifts to fundamental fairness. A growing number of Republican voters, conservative thinkers and even the occasional member of Congress are starting to see the logic in this. While a wholesale, start-from-scratch healthcare system might not be palatable to those on the right, expanding the government programs that already work quite well—Medicare and Medicaid—is certainly plausible.
The American system of privatized, employee-based insurance was never sustainable, either from an economic or a moral standpoint. The time has come for us to catch up with the rest of the world that trounces us in terms of medical outcomes and costs, not to mention patient satisfaction.
Now that Americans have had a taste of fairness in the system, it will be impossible to go back. The only question is how much pressure will it take for our elected leaders to catch up with public opinion?