Healthcare is very important to everyone. That makes sense. We typically receive medical services when we are born and continue to receive medical services all through our life to our last days on this earth. Many regulations surround healthcare in the United States, from licensing of providers to standards of care to coverage requirements. These types of regulations have been in place for decades, and we collectively rely on them. No one wants someone without training to perform surgery on them or fail to use sanitized equipment. No one wants health insurance policies to have loopholes and exceptions that prevent you from receiving care or having procedures covered by that insurance.
Health insurance is complicated. I have worked as an accountant for a medical services company and also for a company that served people with intellectual disabilities. Reading health insurance contracts can make your eyes glaze over and some of the provisions do not make much sense. Negotiating health insurance for employees can be frustrating with the high price tag and the significant implications of the decisions made. Insurance companies act within the regulatory system and aim to stay competitive in the market. The United States government has direct influence in the structure of the healthcare system and health insurance. One reason is that healthcare is a public concern. Another reason is that the government has been a part of the healthcare business, especially since 1965 when Medicaid was created to provide states with matching funds to provide medical assistance to low-income people and 1966 when Medicare was created to provide healthcare to seniors and people with disabilities. Prior to those initiatives, the Veterans Administration in 1930 began providing healthcare for those that served in the military.
The healthcare and insurance industry had been relatively stable during the 1970s through the 2000s. There were many changes in regulations, some more strict and some relaxed (and of course some that oscillated back and forth). But no large, systemic changes were made for four decades. Significant changes were proposed and debated, but nothing came to fruition. Still, there were major issues and deficiencies in the system and support for healthcare reform continued to grow.
In 2008, President Obama was elected with healthcare reform as a main policy proposal. After months of negotiations, the Patient Protection and Affordable Care Act was signed into law in March 2010. The ACA is the most significant healthcare reform legislation since the 1960s. Medicare was expanded, Medicaid eligibility was expanded, and insurance companies were required to accept all applicants regardless of pre-existing conditions and could no longer drop policyholders when they became ill. Dependents were allowed to remain on their parent’s health insurance until their 26th birthday. These provisions had, and still retain, majority support in the country based off of many polls over the years. Overall the ACA moved from initial opposition to majority support as the provisions were implemented in 2014 through 2017.
Some other provisions were more controversial, such as the requirement for individuals to purchase insurance or pay a fine and requiring more small businesses to offer health insurance to their full-time employees. And the regulatory burden on providers has been greatly expanded. It is interesting to me that not all of the opposition to the ACA was from people who thought the legislation did too much. Many people opposed the ACA because they thought the legislation did not do enough. Some unpopular provisions were rescinded later, such as the fine for being uninsured.
Multiple attempts have been made to repeal the ACA, both through the judicial system and in Congress. The closest Congress has come to repealing the ACA was in July 2017 when three Republican Senators (Susan Collins, John McCain, and Lisa Murkowski) voted against repealing the bill. The currently divided Congress, with Democrats in the majority in the House of Representatives and Republicans in the majority in the Senate, has not made any significant healthcare reforms.
President Trump actively supports repealing the ACA. In addition to advocating for bills that would repeal or replace the ACA, his administration has also attacked the bill through the courts. Joe Biden has supported revising the ACA by initiating a public insurance option while keeping many of the provisions in the bill.
It is my opinion that the healthcare system in the United States needs significant change. The current profit-taking by insurance company and pharmaceutical makers drives up the cost of care. So does the rising cost of higher education. The opioid crisis is one of the most significant public health challenges that we need to make progress on. Covid-19 has put healthcare on display on the nightly news.
One benefit of the ACA was to allow more people to obtain and keep health insurance. It is my belief that it is in everyone’s best interest to have more people insured, rather than fewer. A ‘public option’, an insurance that is run by the government as a competitive entrance into the insurance market, is one proposal that would make sense to try. As always when discussing such a complex system, there are pros and cons to every revision, but a public option is an area that has some promise if implemented well.
There is a significant stigma of being on ‘public assistance’. I know that my pride would have a hard time accepting being on Medicare or Medicaid at my current age (40). Medicare is fine for when I am retired, but at this time it would be hard to swallow. Why do I think that way? I need to reject the stigma of public assistance. The fact is that we are all on public assistance in one way or another. Some examples are: tax credits, public schools, state universities, grants and discounts at private colleges, libraries, and even driving on roads and bridges. These are all more or less public assistance to us. Every time you mail a letter, you are ‘on public assistance’. The United States Post Office is a subsidized program to allow everyone in the United States to communicate at a discounted rate.
Why are any of the above examples of public assistance any different from subsidized housing, SNAP payments (food stamps), free school meals, or Medicaid? It really should not be any different. We should not be ashamed of accepting help when we need it. If we qualify for assistance, we collectively as a country have decided that there is a floor of sustenance beneath which it is not acceptable for people to live.
People will argue that public assistance is a form of socialism. It is, if socialism means that we help each other. It is not socialism as defined in the dictionary, where it is an economic system is set up where many areas of the economy are owned collectively. The United States has many areas where socialism is ingrained in how we do things. How I respond is, if it is okay for veterans, seniors, and people with disabilities to receive healthcare, then it should be okay for the poor to receive healthcare too. To be uninsured is a terrible burden and we as a society have decided that in most cases that is not satisfactory.
However, some people are still uninsured. One area is self-employed people and gig workers. Since much of our economy is built upon service and small business, a public option might help to alleviate the risk of being without insurance to many people. Another large group of uninsured people are those that are unemployed. I experienced this in 2017. I was without insurance for 5 months when I was in between jobs. I could have purchased insurance through the ACA but chose to take the risk that I would not need insurance. It was a calculated risk. I did have to pay a fine under the individual mandate of the ACA.
Tying health insurance to employment seems natural in the United States. However, we are an exception in the world. Among developed democracies, many offer universal healthcare. Great Britain and Canada are good examples of this approach to public health. While universal healthcare seems like an extreme proposal, it has many benefits in the countries that have implemented it. “Medicare for All” is the current terminology for this proposal in the United States. There is not majority support for universal healthcare, but support is growing.
Before I end this discussion, I want to mention paid family leave. Again, many developed democracies provide paid family leave to all citizens. In the United States we have not implemented this benefit. However, the Emergency Paid Sick Leave provided during the Covid-19 pandemic is a first step toward this feature that would be welcomed by many people.
Whether Medicare for All or paid family leave will ever become reality in the United States is dubious. There is significant opposition to these types of measures. Actually, there is significant opposition to most changes. People tend to be more comfortable with keeping the status quo. My opinion is that the status quo in healthcare is not good enough. We can do better and we can help more people through our healthcare policy. I support implementing a public option and continuing to work toward everyone being able to obtain and keep effective and affordable health insurance.
Thank you for reading.