Health Insurance Reform

May 6, 2024


The health-care sector is in many ways the most consequential part of the United States economy. It is a fundamental part of people’s lives, supporting their health and well-being (McCormack et al., 2023). The outcomes of a healthy community are attributed to the healthcare system and the affordability of the system. A well-functioning health-care system is a prerequisite for a well-functioning economy and society (McCormack et al., 2023). Unfortunately, due to the substantial problems within the U.S. healthcare system, these sectors are falling behind effective standards (McCormack et al., 2023). Health insurance reform in countries that lack universal health care is a complex and divisive topic that has staggered efforts to increase access. 

History of Health Insurance

In 2022, over 28.1 million (8.6%) people of all ages were uninsured, which includes 27.7 million (10.2%) people younger than age 65 (Cohen & Terlizzi, 2023). Among children, 3 million (4.2%) were uninsured, and among working-age adults (ages 18-64), 24.7 million (12.4%) were uninsured (Cohen & Terlizzi, 2023). This abysmal number of individuals living in the U.S. without proper coverage highlights the seriousness of the disparity and its diffuse impact. It is important to highlight that although the uninsured rates dropped to record lows in recent years, this is attributed to COVID-19 with pandemic-era expansions in Medicaid coverage in the United States (Cohen & Terlizzi, 2023). Unfortunately, in March of 2023, these coverages were disbanded leading to the disenrollment of millions and the partial resurgence in uninsured rates, as people re-adjust to the administrative hurdles involved in the traditional Medicaid enrollment process (U.S. Department of Health and Human Services, 2023). Many of the current issues with the healthcare system can be attributed to the model that attaches coverage to employment. Currently, the U.S. health insurance system is a convoluted and exhaustive system where coverage is dependent on a variety of factors such as: employment status, income level, health status, and age (The Commonwealth Fund, 2022). Despite the complexity of the system, it is up to individuals to assess their coverage options, determine their eligibility, and select a plan during a narrow annual enrollment window (The Commonwealth Fund, 2022). 

The U.S. insurance system has been predominantly employment-based since the 20th century (Oberlander, 2012). This system of insurance has been maintained throughout various reform efforts over the decades. An employment-based insurance system can be challenging for individuals who are chained to an employer simply for health coverage. Furthermore, this system means that when individuals change careers, they often have to change healthcare providers (Oberlander, 2012). This leads to even more fragmented and ineffective care (Oberlander, 2012). In addition to these belaboring factors, our predominantly employment-based insurance means that individuals face the risk of sudden loss of access should employment be terminated, or face a waiting period when transitioning from one employer to the next (The Commonwealth Fund, 2022). In totality, a system that requires labor in order to access basic human services is outlandish, reprehensible, and furthers the capitalist machine that threatens the very existence of those within.

Barriers to Access

Policy efforts to improve healthcare access have focused primarily on expanding health insurance coverage. The Patient Protection and Affordable Care Act (ACA) sought to improve healthcare quality and expand access to health insurance by expanding Medicaid coverage, and although it has been widely successful in expanding coverage, insurance alone may not translate into access to quality healthcare for everyone (Allen et al., 2017). Historically, there have been many instances in which health insurance expansion was brought forward but quickly disbanded as a result of renegade proponents juxtaposed to its implementation. For example, in 1915 National Health Insurance was proposed by the American Association of Labor Legislation, but was vehemently rejected and coined as a negative form of “socialized medicine” (Oberlander, 2012). President Roosevelt attempted to revive the idea of nationalized health insurance in 1935 and was met with fierce opposition from the American Medical Association (AMA), businesses, and the blooming health insurance industry (KFF, 2021). As failures to implement universal health care continued, the paradigm was switched, focusing on disenfranchised sectors of society with Medicare and Medicaid being enacted in 1965 (KFF, 2021). This ensured coverage for the elderly and the poor who were left behind in this system of health insurance coverage (KFF, 2021). Further attempts at universal health insurance were quelled until the largest expansion occurred in 2010. President Obama enacted the Patient Protection and Affordable Care Act (ACA) which expanded insurance coverage and increased affordability for more Americans (healthinsurance, 2023). The ACA utilized federal and state marketplaces for insurance, which offered premium subsidies for individuals who did not qualify for Medicaid, but struggled to afford insurance otherwise (healthinsurance, 2023). However, this attempt at further expansion caused such opposition that the Supreme Court deemed the federal mandate unconstitutional, thus making insurance access an optional expansion for states (healthinsurance, 2023). Despite furious dissent, the ACA demonstrated a positive impact on access with an estimated 17 to 20 million individuals between the ages of 18–64 gaining coverage in the United States (Novak et al. 2018). Furthermore, the ACA has appeared to have a significant influence on overall health with improvement in diagnostics and reductions in poor birth outcomes and opioid deaths (Soni et al., 2020). This history of health insurance reform attempts demonstrates that the idea of universal insurance coverage is not foreign to the U.S., yet it has consistently been met with repetitive and malignant opposition that has stifled efforts and led to undue health burdens as well as financial constraints.

The Cost of Coverage

The U.S. has perfected the act of housing juxtapositions that serve as a constant reminder of the callous and greedy nature that it harbors. In the U.S. healthcare spending is nearly twice as high as spending in other countries despite similar or lower rates of utilization (Anderson et al., 2019; Papanicolas et al., 2018). U.S. healthcare spending, as in other countries, has been a steadily increasing percentage of the GDP since the 1980s (The Commonwealth Fund, 2020; Lorenzoni et al., 2019). In 2018 the U.S. spent 16.9 percent of the GDP on healthcare, and by 2030 the U.S. is projected to spend almost 20 percent of the GDP on healthcare costs (The Commonwealth Fund, 2020; Lorenzoni et al., 2019). The major drivers of overall cost and utilization difference can be attributed to over usage of expensive technologies, such as MRIs, excessive specialized procedures, such as hip replacements, administrative costs, healthcare waste, and high pharmaceutical prices (Anderson et al., 2019; Shrank et al., 2019; The Commonwealth Fund, 2020). The estimated cost of waste within the U.S. healthcare system ranges from $760 billion to $935 billion accounting for approximately 25% of total healthcare spending (Shank et al., 2019). As a result of wasted expenditures the U.S. is home to some of the worst health outcomes of developed nations with high rates of hospitalization for preventable causes and high numbers of avoidable deaths (Anderson et al., 2019; Shrank et al., 2019). 

The U.S. boasts the most expensive healthcare system in the world, however, its residents suffer as they live unhealthier and shorter lives than their peers in other high-income countries. This increased cost of livelihood, services, and detrimental health outcomes in the U.S. is a symptom of our complex and fragmented system (Anderson et al., 2019). Yet as many suffer lack of access and become inundated with the struggles of activating a chaotic, disparaging and disillusioned system, the health insurance companies are celebrating their record profits. In 2021, the CEOs of the seven largest publicly traded health insurance organizations in the U.S. collectively made over $283 million, and Cigna’s CEO David Cordani, individually earned $91 million (Herman, 2022). These record earnings came on the heels of the COVID-19 pandemic, where UnitedHealth’s CEO received $142 million in compensation (Herman, 2022).  In spite of this global health and health care crisis, insurance premiums, health care costs, and profits have continued to rise. While record-breaking CEO compensation is not the only factor in our high healthcare costs, it is reflective of a system that consistently and overwhelmingly puts profits above the people it is intended to serve (Herman, 2022). The record profits the companies relish in is funded by the endless insurmountable debt that is forced on those who are powerless to its exploitative nature. Over 23 million people (nearly 1 in 10 adults) owe significant medical debt, and about 16 million people (6% of adults) in the U.S. owe over $1,000 in medical debt and 3 million people (1% of adults) owe medical debt of more than $10,000; translating to an astonishing $195 billion in medical debt (Rae et al., 2022). The astronomical debt is intertwined in a toxic relationship with greedy capitalism that weaponizes health access for profits, while instilling servitude riddled with health disparities (Rae et al., 2022). Healthcare is a human right and no one should have to entertain astronomical debt in order to receive medical care that they need to live a healthy and comfortable life.

A Way Forward

In order to see lasting change and positive health outcomes it is imperative that we find ways to control healthcare costs, focus on prevention, and increase access to care. By recognizing and understanding the multifactorial perceived barriers we can ascertain a much needed multilevel approach (Allen et al., 2017). Although navigating this issue is complex, there are pragmatic and effective ways to address it on a system, policy, and practice level (Allen et al., 2017). For example, providing comprehensible coverage and cost information, which can mitigate many system-level factors that inhibit healthcare utilization thus creating a transformative cascade that paves the way forward (Allen et al., 2017). Interventions targeting these barriers, with an emphasis on system barriers, may improve healthcare access and thus improve population health (Allen et al., 2017).


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