A few years ago, a student of my public health history course asked why his mother could not pay insulin without insurance, despite having a full -time job. I told him what I have come to believe: the United States health system was deliberately built in this way.
Often people hear that medical care in the United States is dysfunctional: too expensive, too complex and too inequitable. But dysfunction implies failure. What if the real problem is that the system works exactly how it was designed? Understanding this legacy is key to explaining not only why reform has failed repeatedly, but also why change is still so difficult.
I am a historian of public health with experience in the investigation of access to oral health and disparities in medical care in the deep south. My work focuses on how historical political decisions continue to shape the systems we trust today.
When tracking the roots of the current system and all its problems, it is easier to understand why American medical attention is seen in the way it does and what will be needed to reform it and turn it into a system that provides affordable and high quality care for all. Only by confronting how profits, politics and prejudices have shaped the current system, Americans can imagine and demand something different.
Decades of commitment
My research and that of many others show that the high costs, the deep inequalities and the fragmentation of care are predictable characteristics developed from decades of political decisions that prioritized profits over people, rooted racial and regional hierarchies, and treated medical attention as a merchandise instead of a public good.
During the last century, the medical care of the United States did not develop from a shared vision of universal care, but of commitments that prioritized private markets, protected racial hierarchies and raised individual responsibility for collective well -being.
The employer -based insurance arose in the 1940s, not for a commitment to the health of workers, but for an alternative solution to fiscal policy during the freezing of wages in times of war. The federal government allowed employers to offer tax -free health benefits, encouraging coverage and avoiding nationalized care. This decision limited health access to employment status, a structure that remains dominant today. On the contrary, many other countries with insurance provided by the employer combine it with solid public options, which guarantees that access is not linked only to a job.
In 1965, Medicare and Medicaid programs greatly expanded public health infrastructure. Unfortunately, they also reinforced and deepened existing inequalities. Medicare, a program administered by the Federal Government for people over 64, mainly benefited the richest Americans who had access to stable and formal employment and insurance based on the employer during their years of work. Medicaid, designed by Congress as a federal-state joint program, is aimed at the poor, including many people with disabilities. The Federal and State Supervision Combination resulted in 50 different programs with very variable eligibility, coverage and quality.
Southern legislators, in particular, fought for this decentralization. Fearing the federal supervision of public health spending and the application of civil rights, they tried to maintain control over who received the benefits. Historians have shown that these efforts were mainly designed to restrict access to medical care benefits along racial lines during Jim Crow’s period of time.
Swollen bureaucracies, ‘Rastrero socialism’
Today, that legacy is painfully visible.
The states that chose not to expand Medicaid under the law of low -price health care are overwhelmingly located in the south and include several with large black populations. Almost 1 in 4 black adults without insurance are not insurance because they fall into the coverage gap, that is, they cannot access affordable health insurance, they earn too much to qualify for Medicaid, but not enough to receive subsidies through the market of the Law of Low Price Health Care.
System architecture also discourages prevention oriented attention. Because Medicaid’s reach is limited and inconsistent, preventive care detection, dental cleaning and chronic disease management are often overlooked. That leads to more expensive care and posterior stages than further overloads hospitals and patients equally.
Meanwhile, cultural attitudes around concepts such as “hard individualism” and “freedom of choice” have long been deployed to resist public solutions. In the postwar decades, while European nations built national medical care systems, the United States reinforced a market -driven approach.
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American politicians and industry leaders described more and more systems financed with public funds such as threats to individual freedom, often dismissed as “socialized medicine” or signs of progressive socialism. In 1961, for example, Ronald Reagan recorded a 10 -minute LP entitled “Ronald Reagan Speaks Out Against Socialized Medicine”, which was distributed by the American Medical Association as part of a national effort to block Medicare.
The administrative complexity of the Medical Care System was fired from the 1960s, promoted by the increase in state programs of Medicaid, private insurers and increasingly fragmented billing systems. Patients were expected to navigate billing codes, networks and opaque forms, all while trying to treat, control and prevent diseases. In my opinion, and in other scholars, this is not accidental, but rather a form of profitable confusion incorporated into the system to benefit insurers and intermediaries.
Coverage gaps, chronic divestment
Even well -intentioned reforms have been built on this structure. The Law of Low Price Health Care, approved in 2010, extended access to medical insurance, but preserved many of the underlying inequalities of the system. And by subsidizing private insurers instead of creating a public option, the law reinforced the central role of private companies in the medical care system.
The public option, an insurance plan administered by the Government aimed at competing with private insurers and expanding coverage, was finally eliminated from the Health Care Law at low price during negotiations due to the political opposition of both Republicans and moderate Democrats.
When in 2012 the US Supreme Court made states that the states offered an enlarged coverage of medicaid to low -income adults that earn up to 138% of the federal poverty level, amplified the same inequalities that ACA sought to reduce.
These decisions have consequences. In states such as Alabama, it is estimated that 220,000 adults are still without insurance due to the gap in Medicaid coverage, the most recent year for which reliable data is available, which highlights the continuous impact of the state’s refusal to expand Medicaid.
In addition, rural hospitals have closed, patients renounce care and whole counties lack obstetricians and gynecologists or dentists in exercise. And when people receive attention, especially in states where many remain without insurance, they can accumulate medical debts that can upset their lives.
All this is aggravated by chronic divestment in public health. Federal funds for emergency preparation have decreased for years, and local health departments lack sufficient funds and personnel.
Covid-19 pandemic revealed how fragile infrastructure is, especially in rural and low-income communities, where overflowing clinics, delays in tests, limited hospital capacity and higher mortality rates exposed the mortal consequences of negligence.
A design system
The change is difficult, not because the reformers have not tried before, but because the system serves the same interests for which it was designed. Insurers benefit from darkness: networks that change, forms that confuse, billing codes that few can decipher. Suppliers benefit from a service payment model that rewards the quantity of quality, the procedure on prevention. Politicians reap campaign contributions and avoid guilt through delegation, dissemination and plausible denial.
It is not an accidental network of dysfunctions. It is a system that transforms complexity into capital, bureaucracy into barriers.
Patients, especially those who do not have insurance or have insufficient insurance, are forced to make impossible decisions: delay treatment or indebtedness, ration medicines or skip checks, trust the medical care system or do without them. Meanwhile, I believe that the rhetoric of choice and freedom disguises how limited the options of most people are really.
Other countries show us that alternatives are possible. The systems of Germany, France and Canada vary widely in their structure, but all prioritize universal access and transparency.
Understanding what the US medical care system is designed for, instead of assuming that it is involuntarily failing, it is a necessary first step to consider a significant change.
*Zachary W. Schulz is a professor of history at the University of Auburn.
This article was originally published in The Conversation/Reuters
