No longer will the government ensure that the nation is insured.
The recently passed Tax Cuts and Jobs Act eliminates the penalty for the requirement that all individuals must purchase health insurance, which was made law in the 2010 Patient Protection and Affordable Care Act. While the ACA is increasing in popularity, and even health-care structures like a government-run, single-payer system are being discussed on the left, the tax bill confirms a historical trend: the United States has never fully accepted the notion of health care as a fundamental human right.
The debate over health care as a right guaranteed by the U.S. government that each individual deserves, versus a privilege only for those who can afford it, generates politically charged questions about the role of government in American life. Such a right could be implemented in a number of ways: a government program, such as a federal single-payer system or federally owned health-care system like the Department of Veterans Affairs; government provision of private health care; or through a requirement for employment-provided coverage.
Ensuring health care as a right requires some degree of government intervention, since a private system would inevitably leave some people without access. But eight decades of lobbying by the medical industry has made this difficult by focusing the conversation around the negative consequences of government involvement, rather than the positive benefits of delivering such a right to all Americans.
While Teddy Roosevelt first supported the idea of full health coverage in the opening years of the 20th century, it did not become a potential reality until President Franklin D. Roosevelt’s administration.
In 1935, many of FDR’s advisers and members of Congress wanted a government-run single-payer system included in the Social Security Act. Health-care coverage was considered an important part of the recovery from the Great Depression. The private system was failing to provide access to care for many Americans, largely due to growing costs and a lack of capacity to efficiently distribute resources and care. Providing health care would allow more people to work, thus bolstering the economy and decreasing poverty.
But in the end, Roosevelt and legislators passed on adding medical insurance to Social Security because of opposition from groups such as the American Medical Association.
Physicians organized through the AMA to fight for professional autonomy, including autonomy from any governmental intervention in health care. They argued that any public involvement in health care constituted an intrusion into the patient-physician relationship — something considered sacred to doctors, earned after immense sacrifices during many years of intensive training.
Any intervention that dictated physician decision-making was considered a personal and professional affront to their knowledge and expertise. The AMA feared that a governmental guarantee of health care as a “right” would create such an encroachment on the freedom of physicians to care for patients as they saw fit — first government would pay for care, then it would start dictating care. As such, for most of the 20th century, the AMA argued that the government should not be involved in ensuring universal access to health care.
By the time President Harry Truman again proposed a form of universal health-care coverage in the late 1940s, Cold War fears of communism made any form of collective care a difficult proposition. In this environment, the AMA stepped up its efforts and effectively shut down any hope of achieving public health-care coverage. The New York Times described how the AMA fought against all such governmental health-care proposals “with all the vigor and manpower it [could] assemble,” even though the proposals would keep intact the private delivery system that the AMA deemed so crucial and would avoid government ownership of hospitals or direct employment of physicians.
It was not until 1965 that the AMA reached a compromise with lawmakers on the issue. The Social Security Act Amendments of 1965, which created Medicare and Medicaid, included many provisions to appease the AMA, chief of which was that hospitals and physicians would receive blanket payments for services; Medicare would pay whatever the “usual, customary and reasonable” charge was for a physician or hospital’s services. The AMA also received assurances that even though the government would provide the payment in these instances, it would not intercede in medical decision-making.
But the creation of Medicare and Medicaid did not affect the AMA’s broader feelings toward health care as a government-ensured right.
The organization continued to fear any further increase in governmental intervention as an existential and literal threat to physician autonomy. And the AMA felt like the evolution of Medicare policy in the years to follow justified this concern. Government regulators imposed restrictions on the length of hospital stays, leading to increasing requirements on physicians to justify their medical decisions and the requested payment.
Because of the AMA’s determination to preserve physician autonomy and a profitable economic structure, it strongly opposed the health-care reform plans proposed by President Bill Clinton in the 1990s. Surprisingly, given its strong commitment to these principles, the AMA reversed course in 2009, and supported the original House of Representatives version of the ACA. The House bill included more liberal principles, like a public option as part of the insurance exchanges, than its Senate counterpart. Such an option would provide a federal insurance plan to compete with the private insurance plans in the individualized market, likely resulting in a big shift toward a government single-payer system.
Since AMA policy is made by its House of Delegates, this sea change in philosophy was driven by its physician members. The ineffectiveness of the private health-care system has caused many physicians to advocate more strongly for government assistance to address the disparity of those without coverage. Many other physician organizations, such as the American Academy of Pediatrics and American Academy of Family Physicians, have also supported the ACA.
The AMA’s shift toward supporting some form of a universal health-care provision has not been without controversy, as support for the ACA drove a significant number of members to leave the organization. And yet the organization has remained committed to the ACA in order to secure the coverage gains provided by the law.
With health-care costs continually outpacing inflation and wages, and the failure of the private system to achieve health care for all, more and more Americans support increased government involvement, and increasingly see health care as a right that must be secured by government.
Many of us have experienced or witnessed the debilitating impact of poor health on the well-being of those around us. Many individuals and families struggle to pay health-care bills for treatment of serious illnesses, leading medical costs to be the No. 1 cause of bankruptcy in the U.S. Much-needed care is therefore deferred or spurned by millions of people.
The result has been that 60 percent of Americans — including an overwhelming percentage of millennials — currently believe that the government is obligated to ensure that all Americans have health-care coverage, with 33 percent specifically supporting a federal single-payer option. And 37 percent percent of Americans already depend upon such federal and state programs.
Earlier this year, as I walked along the National Mall, I saw a sign on a church placard that read “Health Care is a Basic Human Right.” As I took a picture of the sign, a gentleman walked by and yelled, “When will you people learn? The idea is ridiculous.” The debate has permeated politics for over a century, and despite dramatic policy shifts in the medical profession and in government, it seems we are no closer to resolving it.