### The Myth of Dysfunction in American Health Care
Many Americans are all too familiar with the narrative that the health care system is dysfunctional—characterized by soaring costs, excessive complexity, and rampant inequities. However, what if this dysfunction is not a mere accident, but rather a design flaw in the system? By examining the historical fabric of U.S. health care, we can better understand why reform has repeatedly faltered and why meaningful change remains elusive.
### Historical Context Matters
As a historian of public health, I have dedicated my research to exploring health care access and disparities, particularly in the Deep South. My work emphasizes that the choices made in the past continue to have a profound effect on today’s health care landscape. By tracing the sources of current systemic issues, we can comprehend more clearly the motivations behind our existing framework and what it would take to transform it into a system that offers comprehensive, affordable health care for everyone.
### A Legacy of Compromise
Research indicates that today’s health care costs, disparities, and fragmented nature are byproducts of decades of policy decisions that favored profit over people. These choices, often influenced by racial and regional hierarchies, have treated health care as a commodity rather than a fundamental public good.
In the 1940s, the rise of employer-based insurance was not rooted in a commitment to worker health but was a product of tax policy changes during wartime wage freezes. The federal government incentivized employers to offer tax-free health benefits, effectively tying health access to employment status—a structure that largely persists today. In contrast, many countries with employer-provided insurance pair it with robust public options to ensure equitable access regardless of job status.
### Medicare and Medicaid: A Double-Edged Sword
The establishment of Medicare and Medicaid in 1965 greatly expanded the U.S. public health infrastructure. Yet, these programs also deepened existing inequalities. Medicare predominantly benefitted wealthier Americans with stable employment histories, while Medicaid, a joint federal-state program aimed at assisting the poor, became a patchwork of 50 different systems with varied eligibility and coverage.
Southern lawmakers, particularly during the Jim Crow era, pushed for this decentralization to maintain control over who received care—an effort deeply intertwined with racial discrimination. These historical decisions laid the groundwork for ongoing disparities, particularly for marginalized communities.
### The Impact of Political Stigmas
Today, remnants of that legacy are starkly visible. States that opted out of expanding Medicaid under the Affordable Care Act are predominantly Southern and often home to large Black populations. As a result, many Black adults find themselves uninsured due to the coverage gap—they earn too much to qualify for Medicaid but not enough to receive Affordable Care Act subsidies.
Moreover, the system discourages preventive care because of Medicaid’s inconsistent scope. Preventive services such as screenings and chronic disease management frequently go unchecked, resulting in more expensive care later on that burdens both hospitals and patients.
### Cultural Resistance to Change
Cultural attitudes emphasizing “rugged individualism” and “freedom of choice” have historically stalled public health initiatives. While European nations established national health care systems post-World War II, the U.S. doubled down on a market-driven model. Politicians like Ronald Reagan famously heralded publicly funded health systems as threats to individual freedoms.
This bureaucratic complexity has further escalated since the 1960s, partly due to the rise of state-run Medicaid programs and a multitude of private insurers. Navigating the intricate web of billing codes, insurance networks, and formulary rules has turned into a formidable task for patients, facilitating profitable obscurity for insurers and middlemen rather than helping those seeking care.
### The Affordable Care Act: A Partial Solution
Even well-intentioned reforms have struggled to dismantle the system’s underlying inequities. The Affordable Care Act aimed to widen health care access but ultimately maintained the central role of private insurance. A proposed public option was stripped from the law amid political negotiations, leaving a significant gap in coverage for low-income adults.
The U.S. Supreme Court’s 2012 ruling that allowed states to decline the expanded Medicaid coverage paved the way for increased inequity. For instance, in states like Alabama, hundreds of thousands remain uninsured due to this coverage gap, underscoring the ongoing ramifications of decades of policy choices.
### Consequences of Disinvestment
Chronic disinvestment in public health infrastructure further exacerbates these challenges. Federal funding for emergency preparedness has dwindled, and local health departments often operate underfunded and understaffed. The COVID-19 pandemic has harshly illuminated the fragility of our health care system, particularly for rural and low-income communities. The pandemic revealed a stark reality—overwhelmed clinics, delayed services, and heightened mortality rates—often are the result of neglect stemming from years of systemic disinvestment.
### Understanding the System’s Design
Reform is not challenging simply due to insufficient attempts in the past; the current system actively serves the interests it was designed to favor. Insurers gain from the complexity, with opaque billing structures and shifting networks aiding their profit margins. Providers are often rewarded based on a fee-for-service model which incentivizes procedures over preventive care. Politicians, riding on donations and a web of bureaucratic responsibilities, evade accountability through a labyrinth of measures, fostering dysfunction while claiming freedom of choice.
### Learning from Other Systems
Patients—especially the underinsured and uninsured—are frequently caught in a bind, forced to make heart-wrenching choices regarding their health care options. While the rhetoric of choice and freedom paints a rosy picture, the reality is that most individuals face constrained options.
Countries like Germany, France, and Canada exemplify that health systems can prioritize universal access and transparency, advocating for public good rather than profit. Understanding that the U.S. health care structure functions according to a specific design, rather than passively failing, is crucial for envisioning and demanding significant reform.
