Why is US health care like this?

Vox reader Mike Lovely asks: Why does the US create new health insurance programs (CHIP, ACA, Medicaid expansion options, etc.) instead of consolidating them into one big program where all insurance carriers participate and all people choose their coverage?

Health insurance in America is a constellation of brands and acronyms: Medicare, Medicaid, VA, Tricare, ACA, CHIP, UnitedHealthcare, BCBS. I just got a headache listing them.

In most wealthy countries, people don’t have to worry about a dozen different health plans — and they don’t live in fear of losing their health care after losing a job. And They receive more affordable, higher quality care than Americans. The paradox of the world’s richest countries having one of the weakest health systems among developed countries has long been a vexing policy problem – without an easy solution.

Why does it work this way? It was more an accident of history and culture than a deliberate plan. Today, the American system works well enough—which is not to say it works too well—that building a better system does not rise to the level of a political priority.

Why does US health insurance work this way?

American health insurance, as we think of it today, began to take shape in the 1920s, as the medical profession was being standardized and modern hospitals were being built. Some employers have begun offering payment for hospital-based services as a benefit to their employees. The company had a large group of employees, some in good health and some in poor health, to spread the risk and make the finances work like modern day insurance.

This arrangement soon became quite the obsession of President Franklin D. Roosevelt bypass It plans to include national health insurance as part of the new deal. Then came World War II, along with Government-mandated wage controls for private sector workers Keep the war machine moving. Prevented from offering raises to motivate their workers, companies began pumping up their health benefits—and the government agreed to exempt those benefits from both wage controls and taxes.

In the 1950s, employer-sponsored insurance became available popular Among those who received it and progressive labor organizations called on the government to make the tax exemption permanent. Congress agreed, incorporating subsidies for company health plans into federal law in 1954. Doctors and hospitals, whose industry today was growing into a leviathan, became accustomed to working with private insurers rather than directly with the government.

Today, these work-based health plans still cover about half of all Americans.

So far, so good: but there’s a downside, right?

The problem with the employer-based system was that it excluded many people because they did not work or did not have a job that provided health insurance. To fill the void, in 1965, the Congress was created Medicare and Medicaid To cover the two largest groups that lack coverage: seniors and people in poverty.

After that expansion, we had a system that covered maximum Americans – that made it hard to change, because people were afraid of losing what they had.

These fears, supported by the medical industry’s campaign against “socialized medicine,” have undermined health care overhauls proposed by presidents. Richard Nixon And Bill Clinton That would consolidate most Americans into one national insurance plan. Certain trends in American culture—consumerism and trust in the private market—made it easy to convince the public that they would lose out under government-run health plans.

Meanwhile, there were still glaring holes in the US healthcare system. Instead of threatening the status quo, policymakers added new patches.

Chip Approved in the 1990s, it covered children from working families whose incomes were not low enough to qualify for Medicaid. (Their parents often were, however Left without any coverage.) The 2010 Affordable Care Act, also known as Obamacare, was designed to fill the gap for people who didn’t get health insurance through their jobs but didn’t qualify for Medicaid.

Yet after a half-dozen rounds of incremental health reform over five decades, About one in 12 people People in the United States lack health coverage, and Americans are far more likely than in other developed countries They avoid medical care because of cost.

How do other countries provide health insurance?

Other countries have developed their health care systems more deliberately.

After World War II, the United Kingdom sought to extend medical security to all its citizens by creating the National Health Service; Many other European governments followed suit.

Half a century later, another wealthy island nation made the same choice. TaiwanTo build a modern democracy after decades of autocratic rule, a broken, inequitable health system was abolished and a national insurance program was established that would cover everyone. It was a declaration of solidarity after the end of a tumultuous military dictatorship.

Not all countries have opted for a single government program, but their systems still existEasier than America and covers the entire population. In 2006,The Netherlandsdecided to trade an ineffective two-tiered insurance system for a universal program that relied on private coverage but was nevertheless designed to insure everyone. There today the uninsured rate is less than 1 percent (some people opt out).

But the United States? We have never stopped building a fair, simple, uniform healthcare system.

As Ue Reinhardt, the late distinguished health care economist at Princeton, do it“Canada, and virtually all European and Asian developed countries, reached a political consensus decades ago to regard health care as a social good. In contrast, in the United States we have never reached a politically influential consensus on this issue.”

Will we ever make US health care easier?

The 2020 Democratic presidential primaries, in which several candidates have expressed “Medicare for all” proposals, could be a high-water mark for Americans who want to see a streamlined health insurance system that covers everyone in one program.

Sen. First championed by Bernie Sanders (I-VT), Medicare-for-All would cover all Americans through a federal government insurance plan with minimal out-of-pocket costs. But moderates rejected the proposal. Joe Biden instead promised to pursue his iterative reforms, and Kamala Harris is now taking over Same tack.

A public option, which would give more people the choice to participate in a government insurance program like Medicare or Medicaid, seems more achievable than single-payer. But Biden didn’t even try to pass that policy while on the campaign trail, because he didn’t want to jeopardize his other policy priorities with a politically risky health care proposal that the medical industry might oppose.

Still, if you ask me what the path to a healthy health care system might look like, that would be the model: voluntary adoption among Americans. Proponents of the public option have long argued that if the government could compete directly with private insurers, it could win. Three states recently implemented their own public options — so we may soon get an idea of ​​whether that proposal holds true.

In my own reporting, I hear that employers are rethinking whether they want to shoulder the expensive, burdensome responsibility of managing Americans’ access to health care. Some companies dropped their plans and instead chose to pay for their employees to purchase insurance in the ACA Marketplaces.

It may be that the shortcomings of American health care will eventually lead us to the same point that virtually all of our peer countries have reached, seeking to begin with a universal program. Most likely, at least in the near term, we will keep our unnecessarily complex systems, make marginal improvements and hope for the best.

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