The Long Journey to Healthcare for All

The time has finally arrived. We have reached the point in history where there is a broad consensus that every American should have access to affordable health care. The debate is no longer over whether health insurance is a necessity, or whether the government has a role to play in how the system works. The only things left to debate are the details: What system should we choose to provide universal coverage, and where must we compromise in order to build a majority willing to pass legislation?

This statement captures the mood of the nation:
“Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”
I would ask you to guess which of the current presidential candidates issued this proclamation, but that would not be fair. Any of the major candidates could have said this. However, this is not a statement from the 2020 presidential campaign. The speaker was President Harry Truman, and the year was 1945. 

We have been grappling with healthcare reform for a very long time—seventy-five years if you start the clock with this proclamation—and it has been quite a journey. Truman would have to wait two decades before his vision of a publicly funded health insurance plan came to fruition, albeit only for the elderly. It was a compromise, but Truman was proudly standing in the Oval Office on the day President Johnson signed the Medicare Act in 1965.

Since then, healthcare reform has progressed in fits and starts. The Medicaid program also started in 1965, but it would take until 1982 for all states to participate. In the 1970s, President Nixon signed legislation that expanded Medicare to cover the disabled and those with end-stage renal disease. Under President Reagan, Congress enhanced the portability of employer-sponsored insurance (COBRA) and guaranteed access to emergency care—regardless of ability to pay—with the Emergency Medical Treatment and Active Labor Act (EMTALA). The journey continued but the pace remained slow.

There have been a few setbacks (the failure of President Clinton’s comprehensive health care plan in 1994), missteps (Medicare Part D and its capricious “donut hole”), and rare victories (passage of the Children’s Health Insurance Program in 1997). There have also been wrong turns. A prime example is the misguided—and for now, unconstitutional—scheme to impose Medicaid work requirements, which may cost more to implement than the money saved by kicking people out of the program.

Perhaps the most disappointing stumble has been the failure of 22 states, including South Carolina, to expand Medicaid. In doing so, our state has rejected billions in funding, imperiled the financial viability of rural hospitals, and left over 100,000 of our fellow citizens in a coverage gap. We can debate the politics of Medicaid funding, but the evidence of harm is undeniable. Last year, a study by the National Bureau of Economic Research reported that full Medicaid expansion would have prevented nearly 16,000 unnecessary deaths.

This year we celebrate the 10-year anniversary of the Affordable Care Act (ACA), signed into law on March 23, 2010, after a convoluted and raucous journey through Congress. I use the word “celebrate” with some trepidation since barely half of all Americans have a favorable opinion of the ACA. Opposition to the ACA has hovered consistently around 40 percent, and Congress has voted to repeal the law over 60 times. All attempts thus far have been unsuccessful, the last attempt culminating in a pollice verso moment worthy of a Frank Capra film.

Despite mixed opinions when taken as a whole, there is very strong support for each of the major provisions of the law. According to a 2018 poll conducted by the Kaiser Family Foundation, the majority of Americans (including registered Democrats and Republicans) strongly support:
  • Allowing young adults to stay on their parent’s insurance plans until age 26 (82%)
  • Creating health insurance exchanges where small businesses and people can shop for insurance (82%)
  • Providing financial help to low- and moderate-income Americans who don't get insurance through their job (81%)
  • Eliminating out-of-pocket costs for preventive services (79%)
  • Expanding Medicaid to cover more low-income uninsured adults (77%), and
  • Prohibiting insurance companies from denying coverage because of a person’s medical history (65%).
It is a peculiar stance. Disliking the ACA while being in favor of all of its component parts is a little like finding apples and piecrust delicious, but wanting to outlaw apple pie because everyone might get a slice.

The ACA has been surprisingly resilient, weathering legal challenges, and succeeding in expanding coverage even after the Supreme Court left Medicaid expansion to the discretion of the states. We may not find out if the ACA survives its latest existential crisis, the Texas, et al. v. U.S. lawsuit, until after the election.

Regardless of how the ACA fares before the Supreme Court, or the results of the next general election, it is difficult to imagine that we would abandon this journey. It is even harder to imagine that we would turn back to the days when healthcare was unavailable to those who could not afford it, and when insurance companies could refuse to sell you a policy if there was a chance you might need to use it.

As we listen to the candidates discussing the benefits of their particular healthcare proposals, we must not lose sight of our goal and become distracted by plans that could never make it through Congress. We should also reject simplistic opposing arguments, especially those that rely on how well the word “socialism” fits on a bumper sticker.

To this day, the United States remains an outlier among developed nations in terms of cost, outcomes, and access to care. There are many paths to achieving healthcare for all, and other nations have used a variety of mechanisms to achieve this—and without sacrificing freedom or prosperity. Our own Academy has published a document that describes the various pathways to achieving universal coverage and offers a framework that prioritizes the role of primary care physicians. It is well worth your time to review this document.

Our journey to providing affordable healthcare to everyone has been long and slow, but it has continued under both Republican and Democratic administrations. Perhaps, Winston Churchill, a contemporary of President Truman, was correct in his assessment of our national character when he remarked, “You can always count on Americans to do the right thing—after they've tried everything else.” Creating a framework that guarantees healthcare for all is still the right thing to do. I have faith that the journey will continue.

This article was published in South Carolina Family Physician.