CHHSM Advocacy Center

Background Information

Advocacy for universal government-funded health care has been ongoing for nearly a century in the US, and this history is helpful to understand how we got to where we are today—where over 5 million American workers have lost health insurance due to the pandemic-driven recession and one-third of GoFundMe campaigns continue to be used to pay for medical bills.

In the late 19th and early 20th centuries, medical treatments were simpler, cheaper, and less effective than what we have today. Medical care was also unregulated. Physicians were more likely to treat patients in their homes, with the patients paying modest out-of-pocket fees; and hospitals, which functioned primarily to provide therapeutic-type care, were often run by religious and charitable organizations. Thus, the cost of the health care itself was not the main concern of the patients; it was the lost wages from not being able to work due to illness or injury. According to physician and author Elizabeth Rosenthal, “The earliest health insurance policies were designed primarily to compensate for income lost while workers were ill. Long absences were a big problem for companies that depended on manual labor, so they often hired doctors to tend to workers.”

As effective medical treatments and hospital standards grew in the 1920s, so did the cost of care and the concept of insurance. The model for many of today’s insurance plans can be traced to this period. In 1929 a group of Dallas schoolteachers contracted with Baylor University Hospital to receive up to 21 days of in-patient care a year for regular monthly payments of 50 cents. Similar prepaid service plans were popping up during the Depression era as well. Because the goal of these plans was not to make money, but rather to support patient savings and to keep hospitals functioning, state legislation allowed them to be categorized as nonprofit corporations with tax-exempt status. Within a decade, the model spread across the country and became known as Blue Cross Plans.

More robust insurance plans became needed, however, due to the rapid advancements in medical technology increasing the cost of care. During the same time, companies facing labor shortages found that offering health insurance attracted needed workers. And because the National War Labor Board froze salaries during and after World War II, the federal government supported these employer-based insurance plans and allowed for the money spent on employee health benefits to go untaxed—hoping for a win-win situation.

According to Rosenthal, an untended consequence of this led to the model of employer-based coverage and the boom of for-profit insurance companies, which were focused more on cash than on care. These for-profit plans accepted only younger, healthier patients, and charged varying rates, similar to the model of life insurance. This left many people unable to cover medical bills or to afford or even qualify for insurance if they were unemployed.

Yet, the idea of government-funded insurance was still part of the national conversation. Under multiple administrations from both political parties, several attempts to grant universal coverage were proposed and failed, such as Roosevelt’s Economic Bill of Rights, Truman’s Wagner-Murray-Dingell Bill, Nixon’s Comprehensive Health Insurance Plan, Rep. Dingell’s National Health Insurance Act, and Clinton’s Health Security Act to name a few. Rather than commit to a total health care reform, in 1965 Congress created Medicare and Medicaid programs to provide health care coverage to older adults, those who were poor, and eventually those with disabilities.

The next watershed health care legislation was the Affordable Care Act (ACA) signed into law by President Obama in 2010. By 2016, 20 million formerly uninsured Americans had acquired health care coverage through the new exchanges, the expansion of Medicaid eligibility in participating states, and federal subsidies to help lower- and middle-income Americans buy private coverage. The ACA mostly maintained the structure of coverage through Medicare, Medicaid, and employer-based insurance plans, but it made it so every insurer had to accept all applicants without charging based on pre-existing conditions or demographic status (except age).

Compared to before the ACA, fewer people are uninsured, but more people are underinsured, where they are left to shoulder the burden of high-deductibles and costs related to treatments and prescriptions not covered by their insurance. Research has shown that the greatest loss in the quality and comprehensiveness of coverage has occurred among people with employer-based plans. Of the 194 million U.S. adults ages 19 to 64 in 2018, 45 percent were inadequately insured. While the ACA’s employer mandate imposed a minimum coverage requirement on large companies, the requirement amounts to just 60 percent of a typical patient’s overall costs. Moreover, a gap remains for those who do not have insurance through employment and who are also ineligible for assistance, such as poor adults in states that did not expand Medicaid and undocumented immigrants, who are ineligible for Medicaid and the ACA.

Whether someone is uninsured or underinsured, barriers to health care access significantly impact one's overall health and quality of life. Lack of access leads to unmet health needs, delays in receiving appropriate care, diagnosis and treatment, the inability to get preventive services, financial burdens, preventable hospitalizations, and increased risk for premature death. Data from the Healthy People Midcourse Review demonstrate that there are significant disparities in access to care by sex, age, race, ethnicity, education, family income, and geography. For instance, US rural communities—from the Deep South, Appalachia, Alaska and Hawaii—face disproportionate health problems due to a lack of health professionals and quality medical services, issues related to transportation and remote locations, higher rates of poverty, and language or literacy barriers affecting medical decision-making and communication, to name a few.

As noted in the definitions above, health care access is also about the quality of care one receives after entering the health system, both through coverage and physically into a building. As such, it is essential to note the role racism—through racist policies and beliefs—continues to play in access disparities for People of Color. In the US, Communities of Color, particularly Black Americans, are considerably less likely to receive medical care when needed and when they do, they are more likely to receive a substandard quality of care. According to research, these disparities are evident in every sector of health care. For example, White patients with diseases such as cancer, HIV and diabetes were more likely to receive comprehensive and effective health care than patients of color with the same conditions. This has been shown to be true in maternal and infant mortality prevention, pain treatment and management, end-of-life care, and now COVID-19 treatment and prevention. However, research has also shown that Black babies are more likely to survive under the care of Black doctors and Black patients of all ages are more likely to get better medical care from Black doctors and nurses.

Racism is a long-standing public health crisis, and it is unsurprising that health care has historically been a racialized issue. Although consistent and strong opposition by the American Medical Association and fear-based associations with communism have been key reasons why universal health care has been blocked, more recent research speaks to how racist ideas factor into racist health policies. In his book Dying of Whiteness, physician and researcher Jonathan M. Metzel explains how the frameworks of White racial resentment have shaped attitudes towards public policy—particularly toward health care access—which not only lead to an increase in mortality rates for People of Color, but for the White voters who support the very policies that are killing them too.

As Metzel exemplifies through a patient narrative: “Ain’t no way I would ever support Obamacare or sign up for it,” he told me. “I would rather die.” When I asked him why he felt this way even as he faced severe illness, he explained: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.” Suffice it to say, now more than ever is the time to bring a racial and health equity lens to health care policy and practice.