History of Health Insurance

Most Americans, understand very little about health insurance. The younger we are the more we take health insurance for granted. But it was not always that way.

• Today, a large portion of the population believes that health insurance should be a given right. A smaller but more vocal portion is frightened that they will have to pay for someone who will get something for nothing. The debate that began in the 1930s continues today.

♦ This article was intended to be brief but there have been many important events throughout American history that have shaped our healthcare system and the way we received health insurance coverage.

• Advances in medicine and two world wars played major roles.

Early years

Health insurance is a relatively new thing. There actually wasn't much call for insurance coverage until more medical advances occurred and medicine became more of a science rather than an art.

The demand for doctors and eventually hospitals grew. And from that growth sprung the desire for some form of health coverage to help pay bills.

In the early years the first insurance plans were called Medical Insurance because they dealt with medical expenses incurred treating an illness or injury.

Today's plans still cover medical expenses but they also include preventive benefits to help avoid an illness in the first place. Today's plans also encourage a healthier lifestyle. Hence we call them Health Insurance.

♦ Health insurance as we generally think of it in the United States really began with the Great Depression in the 1930s.

The Great Depression spans a decade, with 1933 – 1934 being the worst years.

The Great Depression led hospitals and then physicians to implement forms of insurance as a means to assure payment for services.

Advances in medicine

Health insurance grew out of advances in medicine.

It may surprise most people to learn that modern medicine is not very modern. More than 90 percent of the medicine being practiced today did not exist in 1950.

In 1850, the U.S. had around 40,000 people calling themselves physicians. Very few of these physicians had a formal medical education. Many were simply charlatans peddling fake remedies. Medicine was still an art not a science.

• It wasn’t until the beginning of the 1850s and 1860s that medicine as a science was born.

At that time, it was discovered that many diseases were caused by specific microscopic organisms. Bacteria as we commonly refer to today, were discovered to be the cause of infections of wounds and surgical procedures.

♦ The germ theory of disease was born and medicine as a science came to be.

Louis Pasteur and others, using their new knowledge of microorganisms, began developing vaccines.

• Pasteurization of milk came about around 1862. It was quickly mandated, resulting in the death rate among young children plummeting.

In 1891, the death rate for American children in the first year of life was 125.1 per 1,000. By 1925, it had been reduced to 15.8 per 1,000.

♦ The life expectancy of Americans as a whole began a dramatic rise.

This new age of science led to the spread of hospitals for treating the sick.

Until this time, hospitals were intended for the very poor, especially those who were mentally ill or blind or who suffered from contagious diseases such as leprosy.

• Anyone who could afford better was treated at home or in nursing facilities operated by a private physician.

Worse, until rigorous antiseptic and later aseptic procedures were adopted, hospitals were a prime factor in spreading, not curing disease.

• Until the late nineteenth century, hospitals were little more than a place for the poor and the desperate to die.

• In 1873, there were only 149 hospitals in the entire U.S.

As recently as the 1920s, long after the birth of modern medicine, there was usually little the medical profession could do once disease set in. Doctors could try to alleviate some of the symptoms but they let nature take its course. It was the patient’s immune system that cured him or not.

♦ It was only around 1930 that the power of the doctor to cure a disease or make it more tolerable began to increase substantially. That power has continued to grow nearly exponentially ever since.

This new power is modern medicine. There was then the question of how to pay for it. In 1930, Americans spent $2.8 billion on health care which translates to roughly $23 per person.

Hospitals have always had a financial problem from the very beginning of scientific medicine. They are extremely labor intensive and expensive to operate. Their costs are relatively fixed and not dependent on the number of patients being served.

• In 1912, Teddy Roosevelt and the Progressive party endorsed social insurance as a part of their platform, including health insurance.

Initially the AMA supported the idea of universal health insurance. But then, in 1917, America entered World War I and this idea was pushed to the back burner.

In the late 1920s, hospital insurance was born. But it was not like we have today. The first hospital plan was introduced in Dallas, Texas, in 1929. It was offered by the Baylor University Hospital.

The subscribers were 1,500 public schoolteachers who paid 50 cents a month for the promise that the hospital would provide up to 21 days of hospital care to any subscriber who needed it. At the time, the AMA opposed this plan so it did not include physician charges.

The model soon spread to other hospitals. And unlike the Baylor plan, which served the Baylor hospital, these new plans covered services at any hospital in the community.

The first hospital plans paid all costs up to a certain limit. The reason, of course, is that they were instituted not by insurance companies, but by hospitals. The plans were primarily designed to generate steady demand for hospital services and guarantee a regular cash flow.

The daily cost of hospital care per patient was roughly the same whether the patient had a baby, a bad back, or cancer. Today, this “front-end” type of hospital insurance simply would not cover a serious, long-term, expensive-to-cure illness.

• People purchased hospital plans to be protected against unpredictable medical expenses. The downside of these plans was that they only paid if the medical expenses were incurred in a hospital.

As a result, cases that did not really need in-hospital treatment ended up in the hospital. The most expensive form of medical care.

These plans paid the bill for services covered by the policy, whatever the charge. There was no incentive for the patient to shop around. Patients quickly became indifferent to the cost of medical care.

♦ The American Hospital Association (AHA) established a Committee on Hospital Service in 1933 and began approving plans. This committee became the AHA Hospital Service Plan Commission in 1936 and later became the AHA Blue Cross Commission in 1946.

In 1937, the AHA added a standard for all plans - no competition among plans. This meant that the Blue Cross Commission granted exclusive geographic market areas to each approved plan. Even today, each Blue Cross plan has an exclusive market area.

• This system worked very well for hospitals, which wanted to maximize the amount of services they provided and thereby maximize their cash flow. There was no price competition to keep prices in check.

Doctors saw the money flow and they wanted their own payment plans. Blue Shield plans were born. They were designed to mirror that of Blue Cross but to pay for medical services provided by doctors. The first medical service plan, the California Physicians’ Service, was established in 1939.

Blue Shield plans had two key features. First, they required free choice of physician. Second, they were indemnity rather than service benefit plans.

This meant that the plans paid the patient a dollar amount for each covered event; the patient, in turn, was responsible for paying the physician. This is much like the AFLAC® plans of today. The AMA began approving plans in 1939 and followed the model established by the hospitals with Blue Cross.

Most states viewed the new hospital service plans as the prepayment of hospital services, rather than as insurance.

• By the mid-1930s, Blue Cross plans were spreading rapidly around the country. It was at this time that state insurance departments moved to regulate them and force them to adhere to the same standards as regular insurance plans. But the doctors and hospital did not want that. The plans had been devised for them in the first place; they wanted to keep a good thing going.

The American Hospital Association and the American Medical Association worked hard to exempt Blue Cross from most insurance regulation, offering in exchange to enroll anyone who applied and to operate on a nonprofit basis.

The Internal Revenue Service, meanwhile, ruled that these companies were charitable organizations and thus exempt from federal taxes. Freed from taxes and from the regulatory requirement to maintain large reserve funds, Blue Cross and Blue Shield came to dominate the market in health care insurance, holding about half of the policies outstanding by 1940.

• In order to compete, private insurance companies were forced to model their policies along Blue Cross and Blue Shield lines. As a result, hospitals came to be paid almost always on a cost-plus basis, receiving the cost of the services provided plus a percentage to cover the costs of invested capital. There was little incentive for hospitals to be efficient and reduce costs.

In 1934, commercial carriers began offering hospital coverage. Initially, they did not cover physician charges, but they did offer surgical coverage, beginning in 1938. They did so because surgeries were definite events with predictable costs.

These plans provided indemnity coverage. This made the loss in a covered event measurable, based on the schedule of agreed payments per event. The indemnity coverage also avoided provider concerns that the insurer would contract directly with selected hospitals and physicians.

Group practices

Prepaid group practice was the forerunner of managed care. Like Blue Cross, the plans began in 1929 in response to the Great Depression.

Physician opposition to prepaid group practice was common. Some doctors who joined these groups were expelled from the county medical society. This was a serious penalty because hospital bylaws required medical staff members to be members in good standing of the local medical society.

• This action could not stop the movement toward group association.

In 1933, Dr. Sidney Garfield established the Kaiser Foundation Health Plan in California. He was charged with unprofessional conduct, and the state board of medical examiners suspended his license to practice. This ruling was overturned by the courts.

As a result of being denied access to hospitals, the early prepaid plans were forced to build and use their own hospitals. Today some health maintenance organizations (HMOs) continue to own hospitals, plans such as Kaiser-Permanente.

They continue to operate many of their own facilities for reasons of control and efficiency, but originally, they did so because it was the only means of obtaining ongoing access to hospitals.

In 1938, the Justice Department charged the AMA under the Sherman Antitrust Act. The Supreme Court held against the AMA in 1943.

Opposition from the AMA continued, with more antitrust suits filed against various medical societies. As late as 1959, Kaiser physicians were still excluded from the San Francisco Medical Society.

World War II

Most insurance in the first half of the 20th century was bought privately, but few people wanted it. Things changed during World War II.

World War II accelerated changes in the work place. The United States entered the war in December 1941. As men volunteered and were drafted into the armed forces, the domestic economy was stressed by increased demand for war material.

Wartime wage and price controls prevented companies from competing for available talent by means of increased wages and salaries. They had to compete with fringe benefits instead, and free health insurance was tailor-made for this purpose.

• Hence, the start of employer-paid health insurance. A concept that larger companies are trying to continue to this day.

It helped a lot that the IRS ruled that the cost of employee health care insurance was a tax-deductible business expense. Unions came to view health insurance as vital part of negotiated contracts.

The 1940s saw a rapid increase in the number of Americans enrolled in whatever healthcare plan their employers chose to provide.

President Truman

President Truman promoted a national health care system in 1945.

This idea had a fair amount of public support. But the Chamber of Commerce and many unions opposed it.

The American Hospital Association and American Medical Association came out strongly against President Truman. The AMA launched a national campaign against all national health proposals.

Confronted by such opposition from all sides, national health insurance failed — for not the first or last time.

• In 1946, the Hill-Burton Act (Hospital Survey and Construction Act) was passed. Its purpose was to speed the construction of hospitals, nursing homes and other healthcare facilities. Federal grants and loans were used for construction and modernization. By the turn of the century, around 6,800 facilities in 4,000 communities had in some part been financed by the law.

Cherry-picking

Soon insurance companies figured out they could increase their profits if they cherry-picked businesses with healthy employees.

This concept favored companies that were least likely to have injuries or whose workers tended to be younger. The effect though was to drive up the cost of insurance for everyone else.

President Eisenhower

In 1954, President Eisenhower proposed a federal insurance fund to enable private insurers to broaden their groups of people they would cover.

• In 1956, a military “Medicare” program was enacted to provide government health insurance to dependents of those in the Armed Forces.

In 1957, the AFL-CIO decide it could now support government health insurance. The AMA continued to strongly oppose any form of national health insurance.

AHA’s Blue Cross Commission spun off from the AHA with the creation of the Blue Cross Association in 1960. It merged with Blue Shield in 1977 to form the Blue Cross and Blue Shield Association.

♦ Blue Cross and Blue Shield plans were pretty simple in their early years. The plans engaged in community rating.

This meant that all subscribers of a plan were in one large risk pool. This rating concept could not continue due to competition from commercial insurers targeting less risky customers within a community. They offered lower premiums to groups with low claims experience. A concept that became known as experience rating.

Blue Cross and Blue Shield were forced to switch from community rating or face a future in which they were the insurer of only the highest-cost subscribers.

In the 1960s, the last Blue Cross plan gave up community rating.

♦ In 1960, the Federal Employees Health Benefit Plan (FEHBP) was initiated to provide health insurance coverage to federal worker.

The Great Society – Medicare and Medicaid

From 1961 to 1963, President Kennedy repeatedly presses Congress for a government insurance program for the elderly. The AMA and commercial health insurance carriers strongly oppose.

In 1964, President Johnson continues to advocate for health insurance for the elderly.

♦ In 1965, the federal government entered the medical market with Medicare for the elderly and Medicaid for the poor.

Like we constantly hear today, doctors and hospitals at that time beat their chests and ranted and raved about the horror of what they called “socialized medicine” and how it must not be allowed to gaining a foothold in the U.S.

As a result of their opposition, Medicare and Medicaid were structured much like Blue Cross and Blue Shield. Congress created a separate hospital (Part A) and physician (Part B) coverage that reflected the nature of the coverage under each type of plan. The new thing was that the government paid most of the expenses.

When Medicare and Medicaid proved a bonanza for health care providers, their vehement opposition quickly faded away.

• The two new systems greatly increased the number of people who could afford advanced medical care. The incomes of medical professionals soared, roughly doubling in the 1960s.

♦ The cake came with a most important consequence. The government now had a power to hold over hospitals.

State governments became the largest single source of funds for virtually every major hospital in the country. This gave them the power to influence or even dictate the policy decisions made by these hospitals. As a result, these decisions were increasingly made for political, rather than medical or economic reasons.

• One of the last major events to hit the private health insurance market occurred in the 1970s. It actually started because of troubles with underfunded pension plans.

In 1974, congress responded with the Employee Retirement Income Security Act (ERISA). This legislation was designed to protect defined benefit pension plans.

The legislation also included a relative handful of provisions dealing with “welfare plans” as they called it; health insurance plans. Employer health insurance plans that were self-insured fell under the terms of ERISA and were not subject to state regulation.

Under ERISA, self-insured plans were not subject to state insurance regulations dealing with reserves or coverage requirements. They were also not subject to state premium taxes.

• ERISA resulted in a quiet revolution in the health insurance industry.

Larger companies became responsible for their own claims experience and of course claims risk. Now they could shop for a less costly claims administrator or undertake those activities themselves. In the process, avoid state premium taxes of 2 to 4 percent.

ERISA would lead to the entry of many self-insured employers providing their own coverage.

• In 1974, President Carter proposed Medicaid expansion for poor children under age 6. Called Children's Health Assessment Program. The proposal fails to come to a vote in Congress.

23 years would pass before the Children's Health Insurance Program (CHIP) would be signed into law by President Bill Clinton in 1997.

Computer age

The next revolution in health insurance happened when the computer came of age.

Computers were around for a long time but they were big and clunky and very expensive. The 1970s saw a dramatic drop in price.

The advent of low-cost computing meant that the claims-processing segment became more competitive.

With risk assessment more predictive, rates could be better set to assure a healthy profit. And more risky customers could be either denied coverage or priced high enough they would go somewhere else.

A trend that continued up until 2010 when the Affordable Care Act threw some price controls into the mix.

The 1980s

The 1980s saw rapid increases in health insurance premiums, driven by new medical technology and cost-based reimbursement systems used by insurers and the Medicare program.

In 1983, Congress changed the system Medicare used to pay hospitals. Rather than paying based on allowable costs, it introduced a system in which hospitals were paid a fixed price based on the diagnosis of admitted patients.

At about the same time, and for the same reasons, the private health insurance industry was changing as well. Prepaid group practice plans, now called Health Maintenance Organizations (HMOs), were beginning to enroll more subscribers.

• Kaiser-Permanente is the classic example of an HMO. Kaiser is the health insurer. It contracts exclusively with the Permanente medical group.

New forms of managed care, Preferred Provider Organizations (PPO) and Point-of-Service (POS) plans were beginning to be offered.

Many insurers offered a PPO product. But PPOs were often not health insurers because they frequently did not bear underwriting risk. Instead, they were coordinators of contracts. They entered into contracts with physicians and hospitals and then sold coverage to employer groups and individuals.

Point-of-service (POS) plans are hybrids of HMOs and PPOs.

Premiums spike

• In the late 1980s, premiums for employer-sponsored health insurance were increasing at 18 percent per year, much faster than general inflation.

♦ Individuals purchasing insurance on their own saw staggering rate increases of 25 percent and more. At the the same time, many people were trapped by their insurance company in an expensive plan due to a previous illness what we now call a 'pre-existing' condition.

• The cold heart of the insurance industry was on full view during these years. But it would not be until 2010 that they were taken to the wood shed for their actions.

The first half of the 1990s saw a much lower rate of increase but that was short lived. By the latter half of the 1990s premiums were rising at more than twice the rate of inflation.

• In 1986, COBRA (Consolidated Omnibus Budget Reconciliation Act) is passed. It gives employees who lose the jobs the right to continue with their health plan for 18 months.

• In 1987, the Census Bureau reports that 31 million Americans are uninsured (13% of the population).

Consolidation

The latter half of the 1990s saw the start of providers consolidating. Some hospitals closed while many more merged or joined hospital systems. And physicians joined larger medical groups.

These actions had the effect of reducing competition in local provider markets and reducing the ability of managed care plans to negotiate lower prices.

• Around this time managed care took a turn for the worst in the eyes of the consumer.

Managed care plans started to more vigorously use utilization management techniques to try to control costs and of course reduce the use of more expensive services.

This was the time where terms like “pre-certification” and “gatekeeper” became dirty words. Terms used to limit access to specialists and costly procedures.

Managed care plans were also accused of preventing physicians from discussing more costly treatment alternatives and forcing new mothers and other patients to leave the hospital before it was medically prudent.

• Consumers wanted access to a greater choice of providers as a way of assuring themselves of better care. And less overbearing “gatekeepers”. As a result, narrow HMO networks were pushed to expand to allow greater choice. This movement limited HMO plans’ negotiating power and costs went up.

HMO plans fell out of favor in the late 1990s. PPO plans started to become more popular among individuals and families that purchased coverage on their own. This trend continued well into the early 2000s.

President Clinton

In 1995, President Clinton proposes the Health Security Act. It would have given every American a “Health Security Card” to ensure access to care.

President Clinton's plan called for universal coverage, employer and individual mandates, competition between insurers, with government regulation of costs.

Opposition from the Health Insurance Association of America and the National Federation of Independent Business was strong. Democrats were divided which caused President Clinton's plan to be blocked in Congress.

• In 1997, the Census Bureau reported that there was an estimated 42.4 million (15.7%) Americans uninsured.

In 1997, Medicare gave enrollees the option of enrolling in a Medicare Advantage plans (Part C), instead of Original Medicare. These plans were managed by commercial insurance companies.

Advantage plans tend to constrain beneficiaries to a limited provider network.

• Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans.

Since Medicare Advantage Plans cannot pick their customers (they must accept any Medicare-eligible participant), they discourage people who are sick by the way they structure their copays and deductibles. Still for most people this is more cost effective than Original Medicare plus buying a Medigap policy.

• The downside is that people sign up for these Advantage plans when they turn 65 and are healthy. In later years, when serious health issues appear, the large out-of-pocket expenses and maximum amounts can become burdensome.

There would be the option to change to Original Medicare but that would still result in large expenses unless you can purchase a Medigap policy to pick up some of the charges.

→ In many states, insurance companies are not required to sell any Medigap policies to you in later years. A few states do require one or two policies to be made available. Most states allow insurers to take into consideration your health status and preexisting medical conditions when determining your premium, which can greatly increase the cost.

♦ In 2006, Massachusetts becomes the first state to provide health care coverage to nearly all state residents. The state requires everyone to obtain health insurance.

♦ January 2006, Medicare Part D - Drug benefits goes into effect.

In 2007, the Healthy Americans Act was introduced by Senators Wyden and Bennett. It promoted elimination of employer-provided health insurance with a movement to single-payer insurance modeled on the Federal Employees Health Benefits Program. It went nowhere.

In 2007, the Census Bureau estimates that 45.6 million (15.3%) of Americans are uninsured.

• In 2010, the Affordable Care Act (ACA) was signed by President Obama. The act did not meet many of the Democratic Party's long sought wishes, like universal health care but it did break the norm of the day.

The majority the ACA's provisions did not go into effect until 2014.

HMOs make a comeback

It was the advent of Obamacare that brought HMOs back for a lot of consumers. With the cost control rules of Obamacare, HMO plans began to look more promising to insurance companies.

The majority of plans offered through the Affordable Care Act and the associated Marketplaces are now mostly HMO type plans.

Consumers can still buy PPO plans but the selection has wilted away and the cost has become significantly more than an HMO plan.

Many larger self-insured companies are continuing to offer PPO plans as a form of employment incentive. But with costs rising they are being squeezed to find other means to insure their employees.

The party is ending

Insurance companies see the writing on the wall. The major insures, like United Health Care, started years ago to move into the realm of providing services. They continue to buy up physician practices, outpatient surgical centers and even hospitals.

The smaller players will continue to fight for market share and an ever shrinking profit margin. These folks run the risk of getting so greedy the federal government will be pressured by consumers to step in and slap their wrist.

People are afraid

Before the pandemic, people changed jobs an average of 11 times before they reached the age of 40. Fear of losing health coverage keeps people from switching jobs even when doing so might make their lives better.

People are afraid that Market exchange coverage might not be as good as what they have. They are probably right about that.

They are afraid if they retire, Medicare won’t be as good as their employer’s insurance. They are probably right about that too.

People are afraid that if the Affordable Care Act is repealed, they might not be able to find affordable insurance at all. They can be pretty much assured of that.

Cannot be sustained

This system of leaning heavily on employer-sponsored health insurance is expensive. It is the single largest tax avoidance scheme in the United States.

In 2017, employer deductions for health insurance cost the federal government around $260 billion in lost income and payroll taxes. This is significantly more than the cost of the Affordable Care Act each year.

This system is regressive. The tax break for employer-sponsored health insurance is worth more to people making a lot of money than people making little.

• The availability of employer-sponsored health insurance is unevenly distributed with top wage earners having easier access to health insurance than lower wage earners.

94% of private-sector workers who are fortunate to have earnings in the top 25% can also expect to received employer-sponsored heath insurance. On the other hand, people whose earnings are in the bottom 25% have only a 40% chance.

The current system also encourages people and employers to spend more money on health insurance than other things. This includes less employer spending on wages. As health insurance premiums have increased sharply in the last 15 years, wages have been flat.

Many economists believe that employer-sponsored health insurance is hurting American’s paychecks.

There are other countries with private insurance systems, but none that rely so heavily on employer-sponsored insurance.

Different ways of thinking

There are two fundamental ways of thinking in America when it comes to health insurance.

* The goal of most Democrats since President Harry Truman has been universal health insurance coverage for every American. Along with, requiring insurance companies to ensure all, regardless of pre-existing conditions or status of the individual.

* The core principles of conservatism have been reliance on choice and competition in the private market place. Historically this has been shown to fail unless there is government arm-twisting to play nice.

In 2007, a bipartisan plan was proposed. It was known as the Healthy Americans Act. It would have transitioned everyone from employer-sponsored health insurance to insurance exchanges modeled on the Federal Employees Health Benefits Program. Essentially what our elected officials were getting, everyone would have been entitled to the same.

It harnessed the Democratic desire to get everyone covered to the Republican interest in markets and consumer choices.

The plan could have potentially phased out government programs like Medicaid and Medicare. This would have pleased conservatives. It was actually sponsored by nine Republican senators. The Healthy Americans Act died in Congress.

President Obama

In 2009, President Obama considered many of the ideas proposed in the Healthy Americans Act. But President Obama was frightened that there would be “significant political resistance” to the concept of a single-payer system even if it were modeled after the Healthy Americans Act.

President Obama probably read the tea leaves correctly. The tide had turned with the GOP. It was moving more toward an adversarial position and away from by-partisanship.

In the end, we got Obamacare with a smattering of democratic wishes. And the dream of universal health insurance continues to be just that, a dream.

President Trump

From the start of his presidential term in 2017, President Trump took aim at the Affordable Care Act. He supported many efforts in Congress to repeal the law and replace it with an alternative that would have weakened protections for people with pre-existing conditions, eliminated Medicaid expansion, and reduced premium assistance for people seeking Marketplace coverage.

• The Trump administration supported Supreme Court challenges to overturn the ACA in its entirety. The challenges failed but had they succeeded millions of people would have had been thrown off their health insurance.

After repeal efforts failed and the courts continued to validate Obamacare, the Trump administration settled on a course of hindering and undermining of the Marketplaces.

Medicaid became a dirty word with the GOP implying that lazy people were getting something for nothing.

A movement among GOP controlled legislatures, encouraged by the Trump administration, set out to make work requirements a part of qualifying and keeping Medicaid assistance. Again, the courts foiled most of those efforts.

President Biden

President Biden says that he believes health care is a right, not a privilege.

• The Biden administration set off immediately to undo Trump rules and policies put in place to hinder or weaken the Affordable Care Act and Medicaid.

The Biden administration set about to rescinded Medicaid waivers granted by the Trump administration that imposed work requirements.

• President Biden pushed Congress to pass the American Rescue Plan (ARP) over the objections of the GOP.

Part of the plan increases the Marketplace premium assistance significantly for years 2021 and 2022. Marketplace enrollment took a substantial jump as a result.

• The Biden administration proposes to make these premium subsidy increases permanent. That will depend on the passage of Build Back Better Act (BBBA).

The BBBA would also create a new route for people living in the 12 states that refuse to expand their Medicaid programs.

People living in these states would be permitted to purchase subsidized coverage on the ACA Marketplace for 2022 through 2025. The federal government would subsidize the premiums.

President Biden's wish list will likely be cut short because the Democrats are as divided now as they were in the past.

Looking ahead

Without much pressure for change, it’s likely the American employer-based system will struggle on.

Even the Affordable Care Act did its best not to disrupt that market.

• Some states and even some cities are taking the initiative to provide health coverage and incentives to their residents.

Many factors will continue to influence the health insurance field but the most disturbing continues to be federal and state politics.

An earlier time in our history the American people and those who represent them would have had confidence that government could do good things.

Now Americans seem to prefer the devil they know to pretty much anything else.