In Sickness and in Health: Health and healthcare in American history
Discussion topics from last week’s readings:
Race, Media and the Crisis of Civil Society; From Watts to Rodney King
Historical background – American healthcare arises of unique circumstances. Like many institutions in US, healthcare systems are born in era of little or no oversight or central authority. Treatment is also firmly linked with individualism and kin- or community-based solutions; for the sick, professional medicine is only one of many competing options. Conditions before 20th century hinder any form of organization or standardization. Medical practitioners have no more power in society than ‘quacks’ or ‘snake-oil salesmen’. Hospitals are few in number and focus exclusively on treating the poor. Late 19th century sees advances in medicine which produce a class of professionals, with technical skills. A sea-change in attitudes: from going to ‘see the doctor’ to going to be ‘examined by the doctor’. Alongside advances, doctor’s prestige in society rises – and becomes more coveted. Professionalization begins in earnest, with individual doctors as the primary actors.
Healthcare systems – Earliest healthcare systems aim to increase access to healthcare, as opposed to prevailing institutions that emphasize accident insurance or sick-day reimbursement. Industrialization and urbanization also tend to increase demand for access to healthcare: early healthcare plans represent a way for middle class to better budget for medical treatment, which increases in cost in line with advances in medical technology and infrastructure. By WWII the notion that one purchases healthcare services and goods as remedies for sickness has supplanted earlier ideas about self-reliance and casual treatment solutions. Public health concerns of the state are generally more interested in matters like public sanitation and other matters related to living conditions.
Post–WWII era – United States takes a fortuitous turn towards technical solutions to healthcare problems. Heavy investments in high-tech hospitals and research are favored instead of primary care and preventative medicine (aka social medicine) solutions. Federal funding aims to improve healthcare by investing in technology, not though improving access to healthcare. However, a separate system for the poor, the elderly and veterans is emplaced, eventually becoming (1965) Medicare, Medicaid and Veterans care – the only publicly-run healthcare systems in American history. Later interest in broadening healthcare access (in 1970s) proves to be too late: prevailing norms of private healthcare are too deeply entrenched to be dissolved.
Private healthcare conundrum – Private/public healthcare creates significant paradoxes in American society. For some, healthcare becomes a privilege, something essentially earned, or a reward (employer-provided healthcare), for others it is a right bestowed (e.g. old age or poverty). Technological emphasis also makes private healthcare extraordinarily expensive for individual buyers compared to public or employer-benefit options. Very nature of private healthcare perverts trend toward affordable care: the sickest individuals are the most costly for healthcare companies, which expend notable sums discerning these individuals to reject them coverage: for a private healthcare company the optimal situation is to have only healthy people covered. Pre-existing illnesses become one-way ticket to poverty in its various forms. Added to this, healthiest individuals tend to avoid buying healthcare altogether, making the pool of insured pay more than they ought to. Top 5% of population cost healthcare providers 50% of their total expenses; the top 10% cost 70% -- these sums represent far more than the individual client actually pays for their healthcare. Cf. the least-costly individuals (50% of total) cost providers 3%. As overall healthcare costs continue to rise throughout the post-war era, increasing 1% of GDP every 34 month in the 1980s, the government attempts to address issue of rising costs.
Affordable Care Act – ACA, or Obamacare, is the end result of nearly 40 years of hesitation on addressing the link between healthcare costs and healthcare coverage. Historical consensus on root causes of the problem of high healthcare costs is ignored for fear of touching a complex, politically toxic issue. Ideas about privilege and morality about access to healthcare undermine the efforts of most politicians. Typical solutions tend to be only stop-gap measures, or even paradoxical (conservative push for unregulated markets or more reliance on private healthcare). By 2000s issue has festered so long that broad swaths of middle class consider healthcare costs their biggest financial worry. ACA takes a conservative tack to problem of coverage: all Americans must be covered or else pay a fine. To ease access and costs of healthcare, ACA forces private providers to offer heavily subsidized private plans. The plans are subsidized by government based on individual’s income. Medicaid is also expanded (though not comprehensively due to conservative intransigence) as is Medicare. Underlying goal is to decrease costs by having entire population enrolled. Many conservatives see Obamacare as immoral deficit spending, or immoral outright (death panels e.g.); many liberals see the solution as catering far too much to the needs of private healthcare providers. Nevertheless 11 million uninsured gain insurance in law’s 1st year and many of the immoral practices of private healthcare become illegal. At present, healthcare costs have not stopped increasing but are increasing more slowly.
“The Political Economy of US Healthcare” in To Live and Die in America: Class, Power, Health and Healthcare, by Chernomas and Hudson