The Mess We Are in (Part I)

A big chunk of my varied career was working in health policy. It’s a field of endeavor that I greatly enjoy.  Basically, health policy identifies health problems and needs and proposes intentional strategies to help address those issues.  I recall a story I heard that helps explain what someone in health policy does.

Imagine people standing by a raging river.  In the river are scores of people who have fallen in the river somewhere, and are struggling, in danger of drowning.  The people along the bank work frantically to pull them out.  Suddenly one of the rescuers stops, looks up-river and begins to walk that direction.  The other rescuers are stunned—where are you going, they shout.  I am going upriver to find out WHY people are falling in the river, and prevent them before they do.

Of course, this is a made up story—but the person who walks up-river to find out why people are falling in the river is a health policy person.  And today the river that people are falling in—nearly drowning or sometimes even drowning—that river is the lack of adequate health insurance.

Some years ago, I heard one of the premier health economists Uwe Reinhardt (http://en.wikipedia.org/wiki/Uwe_Reinhardt) speak.  He opined that if you were to set out to design a system for providing coverage for health care you would NOT design something such as we have in the U.S.

The United States is the only industrialized country that does not provide universal coverage of health care for its citizens.  So how did we get here?  An NPR story, which aired in 2009, gives a good summary of the history of health insurance in the U.S.  You can read the whole article here.

http://www.npr.org/templates/story/story.php?storyId=114045132

What began as a simple way to attract people to stay in hospital beds (the beginning of Blue Cross) , over time morphed into the crazy quilt approach of today— to have health insurance, you basically have to be employed.  How did that happen?  The short version is that during World War II, when industry needed to attract workers, employers offered health benefits as sweetener for employees.  What began as less than 10 % of the population with health insurance in 1940, grew to 63% in the 1950s, and grew again to 70% in the 1970s.  Health insurance was firmly linked to employment and there was no apparent need for a national mandate for universal coverage.

Before the introduction of health insurance for hospital stays through Blue Cross, there had been efforts to join European countries in providing health insurance.  As early as the 1880s, countries beginning with Germany had introduced types of universal health coverage.  Theodore Roosevelt was the first president to actively support health insurance.  The Progressives advanced the concept of health insurance, and won the support of the American Medical Association.  Ironically, they were opposed at the time by some elements of organized labor who saw it as “an unnecessary paternalistic reform that would create a system of state supervision over people’s health” (See http://www.pnhp.org/facts/a-brief-history-universal-health-care-efforts-in-the-us ). 

Other presidents tried to advance the passage of universal health insurance—FDR, Truman , even Nixon, and before Obama, the effort under Bill Clinton that was headed up by Hillary.  As we know, with the introduction of Medicare, the U.S. finally got health insurance for seniors—during President Lyndon Johnson’s presidency.  By that time, the American Medical Association turned from friend to ardent foe.  Medicare was as controversial when it was passed as the Affordable Care Act (aka Obamacare) is now.

And that, dear reader, brings us to the latest efforts to secure universal health insurance in the United States.  

(to be continued)