” In most rich countries, people don’t have to worry about sifting through a dozen different health plans — and they don’t live in fear of losing their health care after losing a job, and they receive more affordable, higher-quality care than Americans do. The paradox of the world’s wealthiest nation having one of the weakest health systems among developed nations has long been a vexing policy problem — without an easy solution.”
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“American health insurance, as we think of it today, started to take shape in the 1920s, as the medical profession was being standardized and modern hospitals were being built. Some employers started offering payments for hospital-based services as a perk for their workers. Companies had large groups of employees, some in good health and some in bad, to spread the risk and make the finances work much like modern-day insurance does.
This system soon became entrenched enough that President Franklin D. Roosevelt bypassed plans to include national health insurance as part of the New Deal. Then came World War II, along with government-mandated wage controls for employees in the private sector to keep the war machine moving. Barred from offering raises to motivate their workers, companies started pumping up their health benefits — and the government agreed to exempt those benefits both from wage controls and taxes.
By the 1950s, employer-sponsored insurance had become popular among those who received it and progressive labor unions urged the government to make the tax exemption permanent. Congress agreed, enshrining in 1954 the subsidy for company health plans in federal law. Doctors and hospitals, whose industry was growing into the leviathan that it is today, became accustomed to working with private insurers rather than with the government directly.
Today, these work-based health plans still cover roughly half of all Americans.”
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“The problem with the employer-based system was it left out too many people because they didn’t work or didn’t have a job that offered health insurance. To start filling in the gaps, in 1965, Congress created Medicare and Medicaid to cover two of the biggest groups of people who lacked coverage: seniors and people in poverty.
After that expansion, we had a system that covered most Americans — which made it hard to change, because people feared losing what they had.
Those fears, supported by the medical industry’s campaign against “socialized medicine,” doomed the health care overhauls proposed by presidents Richard Nixon and Bill Clinton that would have consolidated most Americans into a national insurance scheme. Certain tendencies in American culture — consumerism and trust in private markets — made it easier to persuade the public that they’d lose under a government-run health plan.
Meanwhile, the US health care system still had obvious holes. Rather than threaten the status quo, policymakers added new patches.
CHIP was approved in the 1990s, covering children of working-class families whose incomes were not low enough to get Medicaid. (Their parents, however, were often left without any coverage at all.) The 2010 Affordable Care Act, also known as Obamacare, was designed to fill that gap by covering people who didn’t receive health insurance through their jobs but didn’t qualify for Medicaid.
Yet even after a half-dozen rounds of incremental health reform over five decades, about one in 12 people in the US lack health coverage and Americans are much more likely than people in other developed nations to say they skip medical care because of the cost.”
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“Other countries built their health care systems more deliberately.
After World War II, the United Kingdom sought to extend medical security to all its citizens, creating the National Health Service; many other European governments followed suit.
A half-century later, another wealthy island nation made the same choice. Taiwan, building a modern democracy after decades of authoritarian rule, scrapped a fractured, inequitable health system to set up a national insurance program that would cover everyone. It was a proclamation of solidarity after a tumultuous military dictatorship had come to an end.
Not all countries have opted for a single government program, but their systems are still simpler than America’s and cover the entire population. In 2006, the Netherlands opted to trade a dysfunctional two-tiered insurance system for a universal program that relied on private coverage but was nevertheless designed to insure everybody. The uninsured rate there today is less than 1 percent (some people opt out).
But the US? We’ve never paused to build a fairer, simpler, uniform health system.”
“Vance’s sunny rhetoric here disguises his plan’s inegalitarian moral priorities.
It is true that the young and healthy have different medical needs than the old and sick. And before the Affordable Care Act’s regulations, the former could sometimes procure cheaper insurance tailored to their (currently) limited needs.
But this came at a social cost. Insurers were able to offer cheap health coverage to those who barely needed it by screening out those with preexisting conditions. In Vance’s terminology, they constructed low-risk pools: By only including people who were unlikely to require expensive treatments in their plans, they could profitably provide low-premium insurance to the young and well.
Meanwhile, sick and/or older Americans on the individual insurance market either went without coverage or were forced to pay dramatically higher premiums in order to cover the high cost of their care. Some state governments tried to defray this cost somewhat by subsidizing high-risk pools. But enrollees still paid much higher premiums than the typical market rate, and their coverage often excluded the treatments they needed most.
The Affordable Care Act effectively forced the healthy to subsidize the sick. It required insurers to include those with preexisting conditions in their plans and cover all medically necessary procedures. To guarantee that insurers could still turn a profit and that coverage remained (at least somewhat) affordable for all, the government provided consumers with insurance subsidies.
The upshot of all this was that coverage became a little more expensive for some healthy people, while growing much cheaper for the old and seriously ill.”
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“Vance’s vision for health care policy helps clarify the character of the right’s burgeoning “populism.” On trade and immigration, Vance’s ideology may prize a nationalistic conception of the common good above free markets. But on most economic questions, its iconoclastic rhetoric belies its fealty to conservative orthodoxy — and thus, to “the ruling class” whom Vance loves to deride.
As Trump’s running mate, Vance is campaigning on tax cuts for corporations and the wealthy and deregulation for health insurers. The rest of Trump’s economic agenda is rather hazy. But if his first term is any guide, it would also involve curtailing workers’ collective bargaining rights, reducing workplace safety standards, and attempting to throw millions off of Medicaid. Vance has not seen fit to criticize any aspect of this record.”
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“For Vance, deregulating insurance markets at the expense of the vulnerable is not neoliberal or anti-populist. But arguing that politicians should not spread incendiary lies about immigrants is.”
“A GOP experiment forcing low-income people to work to qualify for public health insurance benefits is stumbling in Georgia.
The state’s Republican governor, Brian Kemp, expected 31,000 Georgians to sign up in the first year of the program, which started in July. Through four months, only 1,800 people enrolled — and critics blame the paltry expansion on an overly complex program with too many hurdles for people to clear.”
“Mining companies offer good jobs with good benefits that can counterintuitively damage health care access. Health systems can grow dependent on those insurance plans to survive, and the benefits are in some cases so good that providers are reluctant to serve others in the community. It’s the consequence of a national health care system that feeds off employer-sponsored health insurance to turn a profit, and, as a result, warps itself to meet the needs of those who have it.
Six months of interviews with more than 90 patients, providers, retired miners, community leaders and health care experts across the U.S., including in three towns characteristic of the mining industry’s past, present and future — Williamson, West Virginia; Elko, Nevada; and White Sulphur Springs, Montana — reveal the breadth of these perils: retired and injured miners, and their families, struggling to get care; communities left with beleaguered or closed health facilities; and pricy hospital bills in towns where mines have driven up median incomes.”
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““Doctors want these big reimbursements from the very rich insurance policies that the gold mine provides. They don’t want the pennies they receive from Medicare,” said Jan Brizee, former ombudsman for the Nevada Office for Consumer Health Assistance representing Elko and other rural counties. “So you have somebody who’s retired after 25 or 30 years, and now they have nothing, having to travel out of town to get even primary care, let alone a specialist.”
Not all mining communities experience these problems, and similar issues exist in towns dependent on other industries with good benefits, like manufacturing. But mining communities face unique obstacles compared with other one-company towns — including remoteness and challenging geography — that make it difficult to attract other businesses that would diversify their health insurance landscape.
Miners also tend to be in worse health than their counterparts with other manual labor jobs, with higher rates of poor sleep and heart disease.”
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“Medicaid expansion and extra federal funding to support rural health centers and hospitals have helped in some towns. But providers bemoan stingy state Medicaid reimbursement rates that aren’t enough to pay the bills, paltry federal funding to support primary care and hospital designations that don’t meet the needs of all facilities.
For the most part, these solutions have inadequately addressed the systemic failures of employer-based health systems in these communities.”
“Universal health care remains an unrealized dream for the United States. But in some parts of the country, the dream has drawn closer to a reality in the 13 years since the Affordable Care Act passed.
Overall, the number of uninsured Americans has fallen from 46.5 million in 2010, the year President Barack Obama signed his signature health care law, to about 26 million today. The US health system still has plenty of flaws — beyond the 8 percent of the population who are uninsured, far higher than in peer countries, many of the people who technically have health insurance still find it difficult to cover their share of their medical bills. Nevertheless, more people enjoy some financial protection against health care expenses than in any previous period in US history.
The country is inching toward universal coverage. If everybody who qualified for either the ACA’s financial assistance or its Medicaid expansion were successfully enrolled in the program, we would get closer still: More than half of the uninsured are technically eligible for government health care aid.
Particularly in the last few years, it has been the states, using the tools made available by them by the ACA, that have been chipping away most aggressively at the number of uninsured.
Today, 10 states have an uninsured rate below 5 percent — not quite universal coverage, but getting close. Other states may be hovering around the national average, but that still represents a dramatic improvement from the pre-ACA reality: In New Mexico, for instance, 23 percent of its population was uninsured in 2010; now just 8 percent is.
Their success indicates that, even without another major federal health care reform effort, it is possible to reduce the number of uninsured in the United States. If states are more aggressive about using all of the tools available to them under the ACA, the country could continue to bring down the number of uninsured people within its borders.
The law gave states discretion to build upon its basic structure. Many received approval from the federal government to create programs that lower premiums; some also offer state subsidies in addition to the federal assistance to reduce the cost of coverage, including for people who are not eligible for federal aid, such as undocumented immigrants. A few states are even offering new state-run health plans that will compete with private offerings.”
“Research has shown that people will skip necessary care if they have even a small cost to pay, and recent surveys find one in three Americans say they have postponed medical treatment in the last year due to the cost.”
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“The Perry Undem survey, which polled nearly 2,700 Americans on behalf of the American Cancer Society’s Cancer Action Network, the Leukemia and Lymphoma Society, and RIP Medical Debt, also detected widespread struggles to afford health care. About 7 in 10 people say they have received a medical bill that they could not afford, it found, and more than 60 percent of Americans said they had made some kind of sacrifice — delaying care, skipping appointments, changing the food they buy at the grocery store, etc. — in order to afford health care in the past two years.”
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“About 40 percent of people said they were always or frequently unsure how much their medical services would cost after they received care, according to the Perry Undem survey; another 30 percent said they were uncertain about the costs at least some of the time. Nearly two-thirds of US patients said they were at least sometimes unsure how much their insurance plan would cover after being treated.”
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“About 6 in 10 Americans said they had experienced a problem using their health insurance in the past year, according to KFF.”
“In the six months since states began double-checking the eligibility of people enrolled in their Medicaid programs for the first time in three years, more than 8.5 million Americans have lost their Medicaid benefits.
Based on enrollment numbers at the start of the year, that means roughly 1 in 10 people covered by Medicaid have lost their health insurance in a matter of months. After the US saw its uninsured rate hit historic lows during the pandemic, millions of the most vulnerable Americans are now falling off the rolls — with no assurance they will be able to find another form of coverage.
Worse, many of those losing coverage are losing it because of administrative hiccups and would otherwise be eligible — a problem that is disproportionately impacting children.
We won’t know until next year’s national insurance surveys how many people simply ended up uninsured and how many people successfully enrolled in another form of health coverage even as they lost their Medicaid benefits. But it is safe to expect that millions more Americans are now uninsured than were at the beginning of the year.
The health effects of this massive loss in health insurance will take years to be realized. But we know that having Medicaid means people are more likely to see a doctor and keep up with managing chronic conditions. The program helps people live longer. So losing coverage will make it even more difficult for a population that already struggles with its health to stay well.
Here’s why this is happening: During the pandemic, Congress approved an emergency provision that prevented almost anyone from losing their Medicaid coverage. Even if you had a change in income or life circumstances that in normal times would have led to you leaving the program, you were allowed to stay as long as that emergency policy was in place. But that provision expired earlier this year, part of the government standing down from its pandemic footing, and states were tasked with double-checking the eligibility of every person who was on their Medicaid rolls — a process referred to as unwinding. Starting in April, they could remove people who they found were no longer eligible.”