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Is The U.S. Healthcare System Dysfunctional? A Look At The Policies Behind High Costs And Unequal Access
Many Americans grapple with the high cost of healthcare, questioning why access remains elusive despite working full-time jobs. Far from being a mere malfunction, the U.S. healthcare system may be operating precisely as intended,shaped by deliberate policies over decades. This reality underscores why meaningful reform remains a formidable challenge.
A Century Of Compromises: How U.S.Healthcare Evolved
The current state of American healthcare-characterized by soaring costs, vast inequities, and fragmented care-didn’t arise by accident. Instead, research indicates these are predictable outcomes of policy decisions that consistently favored profit over people, reinforced racial hierarchies, and treated healthcare as a commodity rather than a fundamental public right.
Over the last century,compromises,not a unified vision of global care,drove the evolution of U.S. healthcare. These compromises consistently prioritized private markets, protected racial hierarchies, and emphasized individual responsibility over collective well-being, embedding deep-seated issues into the system’s foundation.
The Rise Of Employer-Based Insurance
Employer-based insurance emerged not from a dedication to worker well-being, but instead from a tax policy loophole during wartime wage freezes in the 1940s. The Federal Government allowed employers to offer health benefits tax-free, incentivizing coverage while side-stepping nationalized healthcare. This decision linked health access to employment status, a structure that persists today. Many peer nations combine employer-provided insurance with solid public options, ensuring access doesn’t hinge solely on a job.
Medicare And Medicaid: Expanding Access, Entrenching inequalities
The introduction of Medicare and Medicaid in 1965 significantly broadened the public health infrastructure. Though, they inadvertently deepened existing inequalities. Medicare primarily benefited wealthier Americans with stable employment and employer-based insurance during their working years. Medicaid, designed as a joint federal-state program, aimed to support the poor, including many with disabilities. The combination of federal and state oversight resulted in a patchwork of programs with varied eligibility, coverage, and quality.
Southern lawmakers, fearing federal oversight of public health spending and civil rights enforcement, actively sought decentralization, aiming to maintain control over who received benefits. This was designed to restrict access to healthcare benefits along racial lines during the Jim Crow era.
The Painful Legacy: Coverage Gaps And Disparities Today
Today, the consequences of these historical choices are evident. States that opted against expanding medicaid under the Affordable Care Act (ACA) are predominantly located in the South, where many African Americans reside. Roughly 1 in 4 uninsured Black adults remain without coverage as they fall into a coverage gap, earning too much for Medicaid but not enough for ACA subsidies.
According to a recent study by the Kaiser Family Foundation, approximately 2.2 million people are in this coverage gap as of March 2024.
The Architecture Discouraging Preventative Care
The healthcare system’s structure often discourages preventive care. The limited and inconsistent scope of Medicaid means that vital services like preventive screenings, dental cleanings, and chronic disease management frequently fall through the cracks.This leads to more expensive, late-stage care, further burdening hospitals and patients.
Cultural beliefs, such as “rugged individualism” and “freedom of choice,” have fueled resistance to public solutions. While European nations developed national healthcare systems after World War II, the U.S. doubled down on a market-driven approach.
Bloated Bureaucracies And The Fear Of “Socialized Medicine”
American politicians and industry leaders have increasingly portrayed publicly funded systems as threats to individual liberty,often branding them as “socialized medicine.” As an example, Ronald Reagan recorded an LP in 1961 denouncing “socialized medicine,” which the American Medical Association distributed to obstruct Medicare.
Since the 1960s, the administrative complexity of the healthcare system has surged, driven by state-run Medicaid programs, private insurers, and fragmented billing systems. Patients must navigate billing codes, networks, and formularies while managing their health. This complexity creates “profitable confusion” that benefits insurers and intermediaries.
Reforms Built On Shaky Foundations
Even well-intentioned reforms such as the Affordable Care Act (ACA) have been built on this unstable structure. Although the ACA expanded health insurance access, it largely preserved the system’s underlying inequities. Subsidizing private insurers rather than establishing a public option reinforced the dominance of private companies in healthcare.
Political pushback from both Republicans and moderate Democrats led to the removal of a public option from the ACA during negotiations.
When the U.S. supreme court made Medicaid expansion optional for states in 2012, it amplified the very inequalities the ACA aimed to reduce. This decision directly impacted access to affordable healthcare across the country.
The Tangible Consequences Of Policy Choices
In Alabama, approximately 220,000 adults remain uninsured due to the Medicaid coverage gap, illustrating the ongoing consequences of the state’s refusal to expand Medicaid. Data from 2023 shows this stark reality.
Rural hospitals have closed, patients forgo care, and entire counties lack OB/GYNs or dentists. Obtaining care, especially in states with high uninsured rates, can lead to crippling medical debt.
These issues are compounded by chronic underinvestment in public health. Federal funding for emergency preparedness has been declining for years, leaving local health departments underfunded and understaffed.
The COVID-19 pandemic exposed the fragility of this infrastructure, particularly in low-income and rural communities, where overwhelmed clinics, delayed testing, limited hospital capacity, and higher mortality rates revealed the deadly consequences of neglect.
A System By Design, Not Accident
Change is tough because the system serves the interests it was designed to serve. Insurers profit from confusing networks and billing codes, while providers benefit from a fee-for-service model that prioritizes quantity over quality. Politicians receive campaign contributions and avoid blame through delegation and plausible deniability.
This complexity is transformed into capital, and bureaucracy becomes a barrier.
Uninsured and underinsured patients face impossible choices: delay treatment or incur debt, ration medication or skip checkups. Rhetoric about choice and freedom obscures the limited options available to most people.
Countries like Germany, France, and Canada offer choice models that prioritize universal access and openness, despite their structural differences.
Understanding the U.S. healthcare system’s true objectives-rather than assuming unintentional failure-is crucial for enacting meaningful change.
the Future Of Healthcare: Potential Paths forward
Addressing the systemic issues within U.S. healthcare requires a multi-faceted approach. Strengthening the ACA by reinstating the individual mandate and expanding subsidies could improve coverage rates. Concurrently, establishing a robust public option would introduce competition and possibly lower costs.
Investing in public health infrastructure is crucial. Increasing funding for local health departments, emergency preparedness, and preventative care initiatives can enhance community resilience and reduce reliance on expensive, late-stage treatments.
Exploring alternative payment models that reward value over volume, such as bundled payments and accountable care organizations, could incentivize providers to focus on patient outcomes rather than the number of procedures performed.
Furthermore, addressing social determinants of health-such as poverty, food insecurity, and housing instability-is essential. these factors significantly impact health outcomes and contribute to healthcare disparities.
Comparing Healthcare Systems: U.S. vs. Other Developed Countries
The U.S. healthcare system differs significantly from those in other developed nations. Here’s a summarized comparison:
| Feature | United States | Comparable Countries (e.g., Canada, UK, Germany) |
|---|---|---|
| Healthcare Coverage | Mix of private and public insurance; significant uninsured population | Universal healthcare coverage, frequently enough through single-payer or multi-payer systems |
| Healthcare Spending per Capita |
