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Class-based Healthcare

The Health Market Series 

Continuing observations on the nature of the US Healthcare market


How US health coverage most often comes down to where you work

The story is a familiar one. How the US came to have this strange, class-based healthcare system that features fee-for-service payments, funded by non-governmental health plans largely through employers and with no central organizing principle and no assurance of access to community standard quality of care. 

In 1945, Harry Truman was unsuccessful in achieving his proposed universal national health insurance program. As a cohesive system designed to deliver health, no comprehensive national health system has ever been accepted by the American people or Congress.  In fact, no serious progress was made to assure access to health insurance to all Americans until 2010 and the Affordable Care Act. 

Pieces of equitable service coverage have been created, the largest of which are the 1965 Medicare and Medicaid programs. And there have been additions along the way now and then seeking to address focused care expansion and issues of service-payment integration, service consolidation, and systemization to decrease cost uncertainty and variation in quality of care and outcomes. 

One striking outcome of political activity over the past 76 years since Harry Truman’s failed run at national health insurance is the creation of class-based healthcare.  

There are multiple choices we could have made post World War II, but we chose to extend employer-based plans which had been incentivized during the war as a way to provide health insurance to employees. 

Adopting this approach by design is exclusionary since it does not provide access to healthcare during periods of unemployment and historically some focused areas of need like maternal care were ignored. Such a non-standard approach introduces a high degree of disparity and variability to access to community standard care based on what an employer is willing to pay. 

Nothing defines social class in the US as much as occupation and occupational prestige. Linking healthcare insurance or health access to employment guarantees a hierarchical system based on the ability to pay. 

The persistent collective culture and psychology underlying acceptance of an exclusionary healthcare system based on the quality of your job must be complex. It is difficult to conceive of any rationale for the continuing denial of access to equitable, predictable, quality healthcare that persists solely on the definition of where you find your work. 

There are three lotteries in life. Health. Wealth. Relationships. It turns out they are related to each other. One wonders if class-based healthcare as related to employer-based health plans can ever be modified to meet the needs of all the people under all circumstances. Since by nature it is hierarchical, how do we ever level the playing field? 

If we ask the question, what should a successful, humane society provide to its members that gives everyone access to the building blocks needed for successful living, isn’t access to healthcare one of those? At its base, isn’t this something that would make all of us better off? Why are we still fighting about this? 

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