By Emma Watson

With the looming presidential election, healthcare has once again surged to the forefront of political conversation. And, every candidate seems to offer a distinct way to solve the issues of our broken system — promising to make prescription drugs more affordable, to make networks of coverage more transparent, and to reduce burdensome healthcare costs for American citizens. To understand where these leaders are trying to take us, though, it is essential to understand where our country has been. 

The United States showed up to the insurance party pretty late. 

In 1885, with Grover Cleveland as president, the Statue of Liberty was still copper-colored, Mark Twain was preparing to publish the now American classic Adventures of Huckleberry Finn, and Germany’s federal government was passing a series of laws that created the world’s first federally funded health insurance system. More than two centuries later, it appears that we Americans still have not caught up. Our international peers have offered low-cost, universally accessible healthcare options for generations, but America’s efforts — while often well-intentioned — have come up short. 

In the 50 years following Germany’s policy changes, there were some sporadic and mostly unmemorable steps towards change in the U.S. Theodore Roosevelt’s Bull Moose Party endorsed social and health insurance for the first time, but really was only able to offer low-quality care at public hospitals to the absolutely destitute. A decade and a half later, Baylor Hospital created a prepaid plan for school teachers that paved the way for Blue Cross-Blue Shield. And at the tail end of the Great Depression, FDR’s administration made strides in public health measures, but he and his Congress still came up short when it came to insurance. 

It was not until the 1960s that America made much progress. President Lyndon B. Johnson passed America’s first major healthcare payor reform: Medicaid and Medicare. Simply put, Medicaid was created to cover those in the country with the lowest levels of income; Medicare was to offer coverage to those 65 and older, with a chronic disability, or suffering from end-tage renal failure. These payor systems are still in place and, together, they ensure nearly 120 million Americans can receive healthcare. Johnson also oversaw the creation of the Civilian Health and Medical Program of the Uniformed Services, which is the predecessor to  TriCare, which is the government payor that provides health insurance to military personnel and their dependents. 

Towards the end of the millennium, after nearly 40 years of minimal progress since LBJ, Bill Clinton arrived at the White House with the promise of overhauling the healthcare system as we knew it. Within a week of his presidency, he charged First Lady Hillary Clinton and a committee to convene a healthcare reform task force. It ultimately did not make much of a difference: His administration was unable to pass even a bipartisan bill that expanded coverage, though he did pass the Children’s Health Insurance Plan (CHIP). CHIP functions much as Medicaid does and is even run by the same agency. The core difference is that it serves children (and only children) who are “too rich” to receive Medicaid but who otherwise lack a form of insurance, whether it be employer-sponsored or privately purchased.  

All of this brings us to our most modern healthcare reform: the Affordable Care Act. 

In 2010, after a series of amendments, President Barack Obama signed the Patient Protection and Affordable Care Act into law. The narrowly passed ACA (or Obamacare) was a hard-fought battle that required compromise but ultimately insured more than 20 million people. The 974-page statue created a lot of change nationwide, but here is what you need to know to understand what is happening on the 2020 debate stages, have something intelligent to say to Dean Glied, and rile people up at your next family gathering:

  • The ACA protected those with preexisting conditions. Before the Affordable Care Act, insurance companies could refuse to pay for medical expenses that were a product of what they dubbed a “preexisting condition.” This meant that when patients were diagnosed with conditions like diabetes, asthma, or cancer — all of which are incredibly expensive to treat and manage — their insurance company could argue that they had that condition before their coverage began and refuse to pay for the required care. 
  • The ACA created an individual mandate. This requires everyone living in America to have some form of insurance; this can be insurance through your employer, a public payor like Medicare, or privately purchased. This is likely the least popular portion of the law and is currently being challenged in court. The mandate received significant attention from  President Trump and Senate Majority Leader Mitch McConnell in 2017 when the duo tried their best to eliminate it. Ultimately, they were not able to, but the penalty for violating the mandate is now $0. 
  • The ACA increased access to preventative care, which promotes health and reduces overall healthcare expenditure. It is cheaper to give a vaccine than it is to treat polio (and people generally feel better off when they are not suffering from such a disease). This same concept applies to a huge array of services, ranging from mammograms to colonoscopies. This is a big help to the millions of people who put off preventative services because they are too expensive. 
  • The ACA expanded Medicaid. In 2012, the Supreme Court ruled that the federal government cannot force states to expand care, but they do still have the option and the federal funding to cover people up to 138 percent of the federal poverty line. The law also streamlined the application process to remove duplicative paperwork. Nearly 40 states have expanded coverage, leaving largely rural and southern states as the holdouts. 

Obamacare has become the foundation of the nation’s healthcare debate. Since its passage, there have been more than 60 attempts to repeal it, occupying much of McConnell’s summer in 2017. Political leaders on both sides of the aisle have developed different plans to expand, improve, overhaul, and eliminate it. In the next few weeks, we will explore some of these plans. Stay tuned and thanks, Obama!

Emma Watson is in her first year as an MPA-Health student at NYU Wagner. Emma’s area of interest is where social justice intersects public health, and she plans to leverage writing and communication to shape policy, inform communities, and help minority groups advocate for themselves. Her policy and advocacy skills have been leveraged through her roles at Deeds Not Words and the National Academy for State Health Policy.