Why don't we have universal health care?

I’m interested in health care. I’m a licensed professional clinical counselor (LPCC), and I worked as a case manager and care coordinator for over 10 years. In March of 2022 I left my job as a care coordinator with a Minnesota-managed care organization. In this role, I worked primarily with people on medical assistance (also known as Medicaid or MA) who were considered disabled. I talked to them about their health needs and helped them to connect with providers and services that were covered by their insurance. I explained frequently used terminology: levels of care; in-network vs. out-of-network coverage; medically necessary vs. elective care; prior authorization; billing codes and what they mean. It could be rewarding, but it was also stressful. When the work began to take a toll on my health, I decided to take a break.
What interests me now is learning how and why our health care system in the U.S. developed as it did. In his book, "The Social Transformation of American Medicine," Paul Starr examines the history of the medical profession in the U.S. This column focuses on one small piece of that history: how the U.S. came to be the only developed country that does not have universal health care.
It’s not for lack of trying. Americans have been working for universal health care for over 100 years. Presidents Truman, Nixon and Clinton proposed universal health plans, none of which passed. Medicare and Medicaid, passed in 1965, brought us closer, as did the Affordable Care Act (ACA), passed in 2010. Most recently, Senator Bernie Sanders of Vermont and Representative Pramila Jayapal of Washington have introduced Medicare for All legislation.
To learn more about current universal health care efforts, I spoke with Anne Jones, RN, of Health Care for All Minnesota (HCA-MN). HCA-MN is a non-profit organization dedicated to comprehensive, affordable, high quality health care for every Minnesotan. Their partners include Physicians for a National Health Plan (PNHP) and the Minnesota Nurses Association (MNA). Anne is a retired nurse who practiced for over 45 years, including 23 years in the United States Air Force Reserve. Now she volunteers her time working to advance HCA-MN’s goals. Their highest priority: a state-based (or national) universal, single payer health plan.
At the state level, the Minnesota Health Plan (MHP) was developed by Senator John Marty. It is outlined in his book, "Healing Health Care: The Case for a Commonsense Universal Health System." At the federal level, Medicare for All would provide benefits similar to the Minnesota Health Plan: it would eliminate networks, co-pays or co-insurance, and deductibles. Many services that are not currently covered by most health plans, such as dental and long-term care, would be covered. Senator Sanders has a bill in the senate (S4204), and Representative Jayapal has a bill in the house (HR1976). Minnesota Representatives Ilhan Omar and Betty McCollum are cosponsors of the House bill.
Anne told me, “While Minnesota is one of several states working on single payer legislation, advocates for single payer financing for health care agree that a national health plan – improved and expanded Medicare for All – would be the best solution to issues related to cost, quality, and access to health care in the U.S.”
The alternative to Senator Marty’s single-payer plan would be a multi-payer plan. Minnesota Senator Jamie Long has proposed a state-level “public option” (HF96, SF49). The public option was part of the Affordable Care Act as it was first written, and was originally intended to be a government run program to compete with private insurance plans. It was removed because then-Senator Joe Lieberman threatened to filibuster the ACA. Now, states are considering implementing public options.
The proposed public option in Minnesota would use an existing health plan, MinnesotaCare. Currently, MinnesotaCare is available to people with incomes at or below 200% of Federal Poverty Guidelines. The proposal would remove that income limit, making MinnesotaCare available to everyone. MinnesotaCare works with multiple insurers, so the proposed public option would be a multi-payer plan.
So, why don’t we have universal health care? For one thing, opposition has been well-organized and well-funded from the start. Insurance and pharmaceutical industries argued against the first proposed national health plan in 1915, and they continue to do so. A study published in October 2022 in the Journal of the American Medical Association (JAMA) Health Forum found that health care lobbying expenditures grew by over 70% from 2000-2020, with pharmaceutical companies among the top spenders.
Another obstacle is disagreement among advocates for universal health care. Here in Minnesota, we have a single-payer and multi-payer option, both described above. Both options are well-designed and would improve health care for Minnesotans.
Finally, it’s no surprise that we are in a highly politicized environment. A Gallup poll conducted in late 2022 found that, overall, a majority of Americans (57%) believe the federal government should ensure health care for all Americans. It looks like we agree, but when we break down these overall statistics by party, it is Democrats and Independents who agree; 71% of Republicans do not think health care is the responsibility of government. Consensus, even among people who appear to agree, is a challenge.
When I left my job last year, I got a bronze plan through MNSure. The premiums are high, but lower than my other option, COBRA. The deductible is also high. I use the skills I learned as a care coordinator to prevent unexpected bills: calling providers, confirming in-network status and billing codes, etc. My health is mostly stable, and I was able to put money into a health savings account when I was employed.
The situation is very different for people who have chronic health conditions, who are self-employed (like farmers), who don’t get health insurance through their employer, or can’t afford to contribute to an HSA. The U.S. has the highest rates of maternal and infant mortality among comparable developed countries, especially in Black communities. Our current system is not sustainable.
This column scratches the surface of a complex topic. Beneath the surface noise – the barrage of information, politicized rhetoric and outright misinformation that comes at us constantly – facts are more consistent and things begin to make more sense, at least from my perspective. Single payer or multi-payer, I hope we can agree on a way forward to providing affordable health care for all Minnesotans and all Americans.

Resources:
• Health Care for All Minnesota, www.hca-mn.org
• The Minnesota Health Plan, https://mnhealthplan.org/
• Physicians for a National Health Plan, https://pnhp.org/
• The Commonwealth Fund, commonwealthfund.org