Health care in the U.S. has a unique history. This retrospective offers a look at the past and how elected officials have shaped health care. It also offers a glimpse into 2020, when Missouri voters may have an opportunity to snatch the gavel and shape legislation by voting to affirm Medicaid expansion.
Health care in retrospect
In the early 1900s, America’s health care system was in a state of flux. Lagging behind European countries in how we valued insuring against the cost of sickness, U.S. doctors were no longer expected to provide free services to all hospital patients.
It was a new era for America. The post-Civil War Reconstruction period had come and gone, giving way to the Industrial Age. Like technology today, railroads led industry—becoming the first to develop extensive employee medical programs.
By 1910, progressive health care reformers gained support as they argued the benefits of health insurance. In the 1920s, penicillin was discovered, although it would take 20 more years before it was used to combat infectious diseases. During the same time, rural health clinics struggled to provide adequate care, and still struggle today.
Meanwhile, the concept of health insurance was becoming less farfetched. General Motors signed a contract with Metropolitan Life to insure 180,000 workers. Ten years later, Blue Cross Blue Shield offered private coverage for hospital care even though insurance professionals warned against it.
Flash forward another decade to the 1940s. President Harry S. Truman’s plan to offer a national health insurance program was denounced by the American Medical Association (AMA) and declared a communist plot by a House subcommittee. (Similarly, those who currently advocate “Medicare for all” are labeled socialists.) At the start of the 1950s, national health expenditures were 4.5 percent of the gross national product or GNP. Today, it’s about 18 percent.
The paradigm shift
With America and Korea at war, attention turned away from health reform. The bottom line was clear cut: America would have a system of private insurance for those who could afford it and a system of welfare for those who could not. On July 30, 1965, President Lyndon Johnson signed Medicare and Medicaid into law.
Concerns about a doctor shortage and the need for more health care “manpower” led to federal measures to expand education in the health professions. As the 1970s rolled around, health care was still in a state of evolution. With support from the federal government, President Richard Nixon renamed prepaid group health plans to health maintenance organizations (HMOs). Concurrently, health care costs rapidly escalated due to Medicare expenditures, inflation, hospital expenses and profits, and technological advancements.
By the 1980s, corporations had integrated the hospital system and consolidated control. Under President Reagan, Medicare benefits shifted to payment by diagnosis instead of by treatment. In response, insurance companies complained that doctors were exploiting the traditional fee-for-service system.
Now jump to 2013. A major health care reform bill, the Patient Protection and Affordable Care Act (ACA), was touted as the remedy for rising health care costs and increasing health care access. This was crucial timing as Americans were battling chronic and often preventable diseases like diabetes, heart disease, and obesity, as well as other conditions like mental health disorders and opioid addiction. Rural health care is still deemed inadequate in some regions because small towns struggle to attract doctors and specialists. And Americans still battle a myriad of health care challenges. However, with help from the ACA, more community health centers were established to meet the needs of the uninsured and underinsured. This helped improve access to care in both the urban core and in rural communities—where the need is greatest.
Today, health care coverage for all is still uncertain. Partisan groups fight and posture rather than focus on the greater good. There are about 2.2 million uninsured people in the coverage gap, too poor to qualify for tax credits through a gutted ACA, and ineligible for Medicaid because their state did not expand benefits. Missouri, a state whose legislators failed to pass Medicaid expansion despite strong advocacy by a broad coalition of supporters, has about 300,000 uninsured people caught in the coverage gap. The majority are among the working poor.
The power shift
Perhaps the tide is changing. Thirty-six states and the District of Columbia have already expanded Medicaid. This includes Idaho, Nebraska and Utah, three bright red states that bypassed contentious legislative feuds and opted to put the issue before the people as a ballot measure during November’s midterm election. The people won.
At the same time, Missouri voters affirmed ballot measures for medical marijuana and a minimum wage increase. As for putting Medicaid expansion on the ballot in 2020, it will take tremendous grassroots effort from organizations, foundations, health care advocates, and the general public to see this very arduous process through. Generally, the process begins with drafting the petition language, filing it with the Missouri Secretary of State’s Office for approval, if approved developing the ballot title and summary, gathering the required number of signatures, and then submitting the signatures to the Secretary of State for verification. (Ballot measures that don’t seek to establish a constitutional amendment require signatures from five percent of registered voters in six of the state’s eight Congressional districts. This constitutes more than 100,000 signatures.)
What Medicaid expansion means to Missourians is health care coverage that extends to individuals through age 64, and who earn up to 138 percent of the federal poverty level ($34,638 in annual income for a family of four, or $16,753 for a single Missourian without a child). Recent public opinion polling indicates more than 60 percent of Missouri voters support Medicaid expansion.
Although the real work has yet to begin, the possibility to shift power from legislators who failed to pass Medicaid expansion may come to Missouri voters in the form of yet another ballot measure in 2020. While this process plays out, let’s stay encouraged, vigilant, critically informed, and engaged as we wait for the opportunity to make landmark change, again, in Missouri’s health care landscape.
UPDATE: Medicaid expansion will in fact be on the Missouri ballot on August 4, 2020. Vote YES on question two, #YesOn2, https://yeson2.org. The last day to register to vote in Missouri, is July 8, 2020. To learn more about voter registration, visit https://www.sos.mo.gov/