Almost all sides agree that the US health care system, responsible for about 17% of our GDP, is badly damaged. Exorbitant costs, low quality, insurance and co-payments that confuse experts, and the ever-growing gap between rich and poor are just some of the problems.
However, this broken system reflects the country’s constitutional foundation and political culture. At the core of both is a strong suspicion of government interference and a disdain for concentrated power, combined with the upholding of individual freedom and personal responsibility.
Translating this ideology into a modern state is a complex endeavor that often leads to constructs resembling the creations envisioned by Rob Goldberg. Nowhere else is this more evident than in the US health care system. The result has been an uncoordinated, and often ineffective, set of programs that do not cover everyone, are very expensive and often provide low-quality care.
The struggles of the past linger in the present, as seen in the dozens of failed Republican attempts to repeal and replace the Affordable Care Act, the Obama administration’s signature act, if damaged.
More generally, ideologically, the state has failed to reach consensus about the appropriate role of government in providing health care to its citizens. Politically speaking, reforming any part of the health care system becomes a third line. However, in practice, government is often left unrecognized, yet it is omnipresent. In fact, over time, governments, both at the state and federal levels, have come to influence every component of the American health care system.
Governments have three main options for providing benefits. They can regulate the behavior of private entities, provide services directly or simply provide financing while services are provided by other entities. In the United States, state and federal governments rely on all three options.
Today, half of Americans get their insurance through their employer. Depending on the nature of the arrangement, these are often subject to a complex web of state and federal regulations.
However, over time, the federal government has taken a greater role than ever in regulating insurance, culminating recently with the passage of the Affordable Care Act in 2010. The federal government also offers generous tax incentives to encourage a guaranteed employer to provide insurance at an annual cost in excess of 260 Billion dollar.
However, despite regulatory action and financial support, more than half of Americans are not covered by employer-sponsored insurance, which requires other, more active forms of government involvement.
Older Americans and some people with disabilities and end-stage kidney disease, about 14% of the population, are covered by a purely federal social insurance, single-payer arrangement, Medicare.
Due to its antiquated design that separates hospital coverage from physician coverage, all working-age Americans must pay into the system that entitles them to hospital insurance at age 65. Voluntary physician and prescription drug coverage is subject to a combination of individual premiums and state subsidies. Many seniors choose to purchase additional insurance protection to compensate for the often limited benefits under these programs. Alternatively, eligible individuals can choose to get comprehensive coverage through private insurance companies in a program called Medicare Advantage.
Coverage for the poor and near-poor was created through a joint state and federal program called Medicaid, which provides coverage for nearly 20% of Americans. Lacking the constitutional power to compel states to take action, the federal government necessarily seeks to lure states into cooperation by bearing the majority of the cost and allowing states broad power in structuring their individual programs. As a result, programs vary widely across states in terms of qualifications and the benefits they have access to.
One strange exception is the way America provides health care to veterans. Paradoxically by nature, in an arrangement that can only be described as socialist, American veterans can obtain comprehensive services, often at no cost, through a national network of clinics and hospitals that are wholly owned and operated by the federal government. Similar arrangements existed for Native Americans.
Those who are excluded from the various and limited arrangements are certainly left to seek coverage on their own from private insurance companies. In fact, with insurance market reforms and ACA financial support, today about 7% of Americans are able to purchase insurance privately, while 9% are still uninsured. Another set of programs seek to provide certainly limited benefits to these individuals, including through emergency rooms, government-supported private community health centers, hundreds of city, county, state-owned clinics and hospitals, and public university systems.
Has the ACA changed anything?
When the Anti-Corruption Act was passed in 2010, supporters praised it for moving the United States in line with its industrial peers. Critics demonized it as the last step toward socialism in America.
Neither side was correct in his assessment.
Within the American system, particularly as it has been used to expand access to health care, the ACA has been so large, but nonetheless natural, that a long series of additional trial and error adjustments to new conditions goes back to the early 20th century. For the most part, the ACA sustains a patched system together of various private and public components by simply pairing some, albeit significant, insurance market reforms with additional funding.
With regard to Medicaid, he simply added more, mostly federal, funding to get more people into the program. For those who buy insurance on their own, it has made purchasing insurance easier by creating online marketplaces and by providing financing to low-income individuals in the form of subsidies for insurance premiums and out-of-pocket costs. Most importantly, it begins with meaningful reforms in the insurance market aimed at facilitating access including the provision of insurance regardless of pre-existing conditions, by limiting the amount that can be charged to the consumer based on gender and age, and by requiring a minimum amount of Services included, among others.
However, even if the ACA were fully implemented, millions of Americans would be left without insurance, and the thorny issues of quality and costs would be left largely untouched.
The American health care system is a complex mixture. Evolving over time, we can see incremental, random adjustments to changing conditions over time, without much rationality or overarching thinking.
Conceptually, one could easily imagine a simpler approach. For example, the United States could adopt a single payer system similar to that found in many other rich industrial countries. In practice, however, limited national power, stark ideological divisions over the appropriate role of national government in health care provision, and the creation of vested interests make politically unlikely other than a continuing evolutionary approach, if not wholly implausible.
In such a system, exploiting the shortcomings of the American health care system and blaming the other side becomes a political imperative. No single party can single-handedly reform the system without risking the wrath of the electorate. In fact, there is not even a basic ideological consensus about what kind of health care system the United States should have.
Under these circumstances, neither party has much incentive to cooperate to initiate the meaningful and necessary reforms to improve quality, access and costs. Thus, we are left with an extremely expensive and often poor quality system that deprives millions of Americans of access to proper care.
Simon F. Haider is an assistant professor of public policy at Penn State University.
This article is republished from The Conversation, an independent, non-profit source for news, analysis, and commentary from academic experts.