On my first day of work I read an office post emblazoned, “The system is not broken, it was built this way.” Before starting at CCHI, I conceptualized U.S. healthcare as a ponderous and inequitable system. I had a general picture of an underinvestment in preventative health and an ingrained fear of what any medical service would cost (an anxiety that I think is shared by many people living in the US). I knew the healthcare system did not work well. But I did not understand just how deeply it was flawed.
One month, dozens of meetings, and hundreds of articles later, that poster’s message remains one of the most pertinent and apt assessments of the healthcare system I have read.
A highly abridged history of the medical healthcare system in the United States:
Before the 1920s, medical care was pretty bleak. Think leeches. Hospitals were non-high tech, usually charity-based organizations “where poor people went to die.” When people sought care they were usually more concerned about the expense of missing work than the cost of the care itself.
Jump to the 1920s to 1940s and we learned new things! Antibiotics appeared and medical care could save more lives. Many European countries established state health care systems in the midst of economic hardship. In the US, however, proposals to create state-run healthcare failed to pass.
Part of this legislative failure was lack of motivation. Health care costs were still relatively manageable for most Americans. “In 1929, the average American family had medical expenses of about $103—roughly 5 percent of the average annual income of $1,916.” The economy was booming. Unlike today, paying for healthcare was not a top concern for most people.
In this period, health insurance appeared in most people’s lives not first and foremost as a way to afford their healthcare, but as a perk tied to certain jobs. Health insurance as a concept was then linked to reputable forms of labor (think office jobs not service or agricultural roles). It became something acquired through socioeconomic status versus a public good available to all. The US government reified this connection in 1943 by making employer-based health insurance tax-exempt.
Importantly, socioeconomic status and access to the type of work that provided health insurance was (and still is) tied to race, gender, familial resources, and other identity markers. Who the healthcare system ‘works’ for is therefore only a slice of Americans.
Speed up again to the 1950s and another burst of medical developments. This time the cost of healthcare goes up significantly and suddenly affording it is often dependent on whether you have the aforementioned employment with good benefits. Healthcare is further cemented as a commodity earned through well-paid forms of labor which in turn is influenced by one’s social positionality.
The increase in the cost of medical care can in part be attributed to the medical breakthroughs and increased range of care hospitals were able to offer. However, with more insured patients, providers realized that the insurers were largely leaving it up to them to set prices. It was no longer a matter of asking the human in front of you for $200 but was now a bill sent off and a reimbursement received from a distant company. The higher the bill, the higher the reimbursement. From the perspective of providers, the U.S. healthcare system rewarded high prices.
The effects of providers charging high prices rippled out. Non-profit insurers were slowly (over the latter half of the century) forced to switch to a for-profit model or go out of business. In order to remain competitive health insurers were forced to focus on business growth over healthcare access. The amount of money health insurers actually spent on healthcare decreased.
On the facility side, healthcare deserts have appeared in areas, often rural, where it is not profitable to provide healthcare. Such deserts further emphasize that the system is not incentivized to provide healthcare but rather to turn profits.
By the 1960s it became unavoidably apparent that packaging health insurance as a supplementary employment benefit left out large swathes of the population. Medicare and Medicaid (publicly funded health insurance for those over 65 and those under a certain income threshold respectively) were deployed. However, while insurance coverage expanded it did so without changing fundamental levers in the market. Healthcare in the US remained driven by profit. The health care facilities that survive are those that make money vs those that provide the best care.
Today health is not distributed equally. Education, socioeconomic status, race, immigration status, and gender identity – all these identities and more are associated with your health outcomes. These inequities are symptomatic of a system that has linked access to healthcare to forms of labor deemed socially desirable. Further, the delivery of healthcare in the U.S. is foundationally tied to a system that rewards prioritizing profits. Just as in the 1960s, improving healthcare access, affordability, and outcomes remains complicated by the fact we are working in a system with conflicting goals. To make money vs to cultivate health.
The work I am now embarking on at CCHI – creating a more equitable, affordable, and accessible health care system for Coloradans – is an exercise in transformation. It is taking a system and recreating it so that all its mechanisms work to support that singular goal. It is complicated and messy and involves a truly unbelievable amount of acronyms. But this mess and confusion is part of the healthcare system’s defense.
The healthcare system does not want to be understood. Being easily comprehensible would reveal ugly truths (i.e. how many decisions are being made based on profits versus patient needs). But it is desperately important to find ways to communicate these truths. Both in order to understand how to change these systems and to communicate these avenues for change with the public.
It took me a month to get to this level of understanding and I still have an incredibly far way to go when it comes to the healthcare market and health policy. However, just the understanding of why my co-worker’s poster is true fuels the questions I now ask and my conviction toward system-level transformation. I look forward to continuing to untangle the mess just as I look forward to the day the poster’s message is no longer pertinent.