The Origins Of A Complex American Health Care System09:07


The problems with the health care system in the United States may seem like they’re new, but they’re not.

Historian Nancy Tomes explains to Here & Now’s Jeremy Hobson how our uneven, expensive and complicated system came to be.

Interview Highlights

On how we got to the current state of the health care system

"As a historian, I have to say, this is not a train wreck that has just developed in the last year since the passage of Obamacare. We have a long and very troubled history in trying to arrive at what other democracies have arrived at, and that is a sense of full coverage for all citizens.

"Decisions that were made as early as World War I, we are now seeing the consequences today. The United States turns its face away from the idea of government involvement in provision of health insurance. Starting in World War I, we developed a very robust system of private insurance, but that was only for people with high-end jobs. So, union workers negotiated and got more coverage in the 1950s. Executives started getting private insurance as part of their employment package. So, insurance became more available, but at a high cost that left a lot of people out, and we're still trying to figure out how to get the lost ones into the fold."

On charity, giving in health insurance

"One thing that Americans have long been averse to is the idea of charity, of being on the dole. So one of the drives behind creating Medicare was to create a program that would take that stigma away. You would be saving in advance, you'd be paying into a system over the course of a lifetime and then reap the benefits when you needed it.

On the prospect of a universal health care system over the years

"The decision was not to go that route because there is a longstanding belief that private is better than public. You only resort to public if you can't get the private to do it. The idea of insuring elderly people, just at the point when they're likely to need more medical care, or very poor people who would present all kinds of health problems, they're just not an attractive population for private insurers. They never have been. They still aren't now. And that indeed is a big part of what we're struggling with at this very moment."

On the beginnings of health care insurance

"As health care got more technologically sophisticated, when you went to the hospital you were having X-rays, you might be having surgery, procedures that were far more expensive, that it would be difficult — essentially the expansion of hospital care was being limited by the fact that few people had sufficient savings to cover a major medical incident. And even though old-line doctors who hated all forms of insurance — they believed if you put a third party between themselves and patients bad things were gonna happen. In some ways they were absolutely correct about that, but the problem was people couldn't afford the care. The hospital couldn't get the debts paid. Medical debt collecting was a very early specialty in the United States. Far better than a system, a private system like that, where the patient is left with debts they can't pay or it takes a lifetime to pay, far better to set up an insurance program that will save money over time and then it's there when they need it."

"There are clearly things that we can do well. But when you look at the dollars that we spend and the outcomes we get, we clearly don’t have it right."

Nancy Tomes

On the burden on patients in the current U.S. health care system

"It requires patients to do more than their counterparts in other countries. Just this morning I was speaking to a group of physicians in the Netherlands, and they simply cannot wrap their heads around the concept of the patient as shopper. That is simply not a concept that you're gonna find in a nation like that. When I said, 'Well, in the United States health care is not considered a basic human right,' they just looked at me as if I had sprouted horns.

On the benefits of our system compared to others around the world

"We've paid a price for the trade-offs that we've accepted over the decades. Are there areas in which American health care provides a superior level of technical care? I think that's absolutely true. But you have to set that up against the dysfunction of the rest of the system. It is so uneven. It's so disorganized. You have to work so hard to get the right care, that it's a trade-off. So I would say yes, in some ways, there are clearly things that we can do well. But when you look at the dollars that we spend and the outcomes we get, we clearly don't have it right."

On whether the system can be fixed or it needs a restart

"Theoretically, I would say it needs to be ripped up and started all over again. Practically, one thing historians learn to respect a great deal is the importance of past choices and how they determine present choices. The strength of the system that we have in place, we have invested in it for so many years that completely knocking it down and setting up, say, a single-payer system, I personally — much as I think that would be a good solution to our problems — I don't believe it will ever, ever happen. The commitment to private insurance and the political strength of the insurance industry is such, I don't believe that will ever, ever happen."

Correction: Due to an editing error, an earlier version of this post's transcription included a misspelling of a reference to "old-line doctors." We regret the error.

This segment aired on March 27, 2017.


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