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The U.S. Health Insurance System

By: Holly Rosenkrantz

Pub. Date: October 23, 2020 Access Date: November 10, 2022

Source URL: https://library.cqpress.com/cqresearcher/cqresrre2020102300

https://library.cqpress.com/cqresearcher/cqresrre2020102300

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Table of Contents

Introduction

Overview

Background

Current Situation

Outlook

Pro/Con

Chronology

Short Features

Bibliography

The Next Step

Contacts

Footnotes

About the Author

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Introduction COVID-19 sparked a recession and massive job cuts, which have cost millions of people their health insurance. An estimated 160 million Americans had insurance through an employer before the pandemic, and as many as 43 million may lose their coverage. The dramatic change could upend the U.S. employer-based health insurance system, as more people join government programs such as Medicaid or use tax subsidies to buy plans on Obamacare exchanges. But a contentious election campaign, in which health care has become an even more prominent issue due to the pandemic, could also alter the long-term outlook for health insurance in the United States. Democratic presidential nominee Joe Biden supports adding a public option to the Obamacare law, and liberals may push for a government-run single-payer system if the Democrats win big gains in the election. At the same time, Obamacare could face a significant threat in November when a conservative-dominated Supreme Court hears a new challenge to the law.

A trauma patient is rushed into an exam area at a hospital in Moreno Valley, Calif., in May. The entire U.S. health system is under great stress because of the COVID-19 pandemic, causing consumers and policymakers to question the effectiveness of the traditional employer-based health insurance system. (Getty Images/Los Angeles Times/Gina Ferazzi)

Overview At the start of the COVID-19 pandemic, April Satterfield's husband was pushed by his employer, an Atlanta-based credit card company, to take early retirement. The family had options for health insurance: They would be allowed to stay on the employer's plan for another year and a half, and their disabled son qualified for Medicaid, the government program that insures people with low income or disabilities.

But Satterfield did not want to take the deal being offered to them as the company was trying to survive the virus-induced recession. Her son TJ, age 8, has a rare medical condition called autoimmune encephalitis, and he relies on out-of-state specialists to manage his care. A government- run plan such as Medicaid, she says, would not cover out-of-state doctors and experimental treatments that have saved his life.

“I am so scared we will lose all his doctors and treatments,” she says. “My son's health is tied to my husband's job.”

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#top

A woman laid off during the COVID-19 pandemic receives unemployment benefits forms in Hialeah, Fla., in April. The massive job losses caused by the pandemic-induced recession have cost millions of Americans their health insurance. (AFP/Getty Images/Chandan Khanna)

The uniquely American situation in which a person's health care is tied to a job has been given a dramatic jolt by the pandemic. It has disrupted the country's health care system, shaking up long-held assumptions about medicine, doctors, hospitals, insurance companies and drugmakers. And it has led some experts to predict the American tradition of linking health insurance to employment will end.

This 75-year-old structure was under stress even before the pandemic due to unsustainable costs for small and large businesses and crippling out-of-pocket expenses for patients. The recession has only added to that pressure by causing millions of people to lose their health insurance along with their jobs.

Before the pandemic hit, an estimated 160 million Americans had insurance through an employer. As many as 43 million people may lose their employer-based coverage as a result of the recession. Many will obtain insurance through the government, a development that has important political ramifications in a historic election year.

Policymakers are considering several options to bolster and preserve the employer-based system. But whether this system can, or should, be preserved remains to be seen. Some experts say evidence is scant that the system is financially sustainable in the long run. Others say that even if it is, it should not be preserved, because it is rife with racial inequities — and those inequities have been exacerbated by a virus outbreak that is hitting racial minorities particularly hard.

“Even before the pandemic, having an insurance card didn't mean you could afford health care,” says Emily Barson, executive director of United States of Care, a Washington-based group that pushes for improved access to health care. “This is a system where people's health care is tied to their job. That is expensive for employers and exacerbates inequities. That is not a measure of a well-functioning system.”

Access to insurance is vital because health care in the United States can be very expensive. A single visit to the doctor's office can cost several hundred dollars and an average three-day stay in the hospital can run tens of thousands of dollars or more.

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In 2020, the cost of health care for a family of four covered by a typical preferred provider plan (PPO) was $28,653, according to the Milliman Medical Index, an annual measure of health care costs done by a Seattle consulting firm. U.S. employers spend about $20,000 per household per year on health insurance for their employees and their families.

And concerns about cost affect whether people seek and obtain medical treatment — decisions that have been complicated by the pandemic. A Gallup Poll conducted in April found that concerns about cost would discourage millions of people — almost one in 10 — from seeking care for suspected COVID-19.

“We have a health insurance system that is essentially pretty good for healthy people who are economically in good shape,” says David Himmelstein, a primary care physician and a professor at the School of Urban Public Health at City University of New York's Hunter College. “And then as the economy goes down, and you get sick or your job goes away, you are in trouble.”

The reason the U.S. health insurance system is so unique is that many other developed countries provide much of their medical care through the government. Every modern industrialized country other than the United States has achieved near-universal coverage, and done so at a lower cost.

Most insured Americans — 67.3 percent — receive coverage through a private insurer, while about one-third get it from a government-provided plan, such as Medicare (the federal health insurance plan for people ages 65 and over), Medicaid (for lower-income people), or special government health care plans for military veterans.

And among those insured through a private plan, 55.1 percent are employment-based, while 10.8 percent comes from a direct purchase from the insurer. (Another 2.6 percent comes from TRICARE, an insurance plan for active and retired military.)

Much of that employer-based coverage comes from bigger companies; smaller businesses are typically least able to afford health benefits for their workers. While nearly all large companies offer insurance to their employees, only 56 percent of businesses with fewer than 200 employees provide coverage.

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Given the cost of health insurance, millions of Americans historically have lacked coverage. Many of them rely on emergency room visits when they need care, or do not seek care for nonemergency situations.

The number of people without health insurance has been dropping, though, since the passage of the landmark Affordable Care Act (ACA), also known as Obamacare, in 2010. The ACA has increased insurance coverage by providing subsidies in the form of tax credits for households whose incomes are too high to qualify for Medicaid but too low to be able to buy insurance at the market price, which is often several thousand dollars a month for a family. At the start of the pandemic, about 90 percent of Americans had health insurance, up from 82 percent in 2010.

Three Miami residents discuss health plans available through the Affordable Care Act (ACA) with insurance agents in 2015. Before the pandemic hit, the ACA had helped boost the coverage rate among Americans to 90 percent. (Getty Images/Joe Raedle)

The ACA also provided significant federal assistance for states to raise their income limits for Medicaid, which is a joint federal-state program. This expansion added many people to the Medicaid rolls who work but still cannot afford insurance. The ACA provision expanding Medicaid suffered a big blow in one of the first legal challenges to the act: The U.S. Supreme Court in 2012 limited the federal government's power to compel states to expand their Medicaid programs.

But as the COVID-19 recession extended through the summer, some 29 million people became unemployed. Layoffs, furloughs and cuts in insurance expenses by struggling small businesses led to more than 3 million adults losing employer-sponsored health insurance, and 2 million becoming uninsured, according to a study based on census data done by the Urban Institute, a Washington think tank. A report by the Economic Policy Institute, a liberal think tank, relying on U.S. Bureau of Labor Statistics data, puts the number of people who have lost their employer- sponsored insurance due to the pandemic even higher — at roughly 6.2 million. And an analysis from Avalere Health, a Washington consulting firm, predicts about 12 million people will lose health care by the end of the year.

(Estimates vary because projections rely on different methodologies. More definitive data will become available next year. )

Whatever the precise numbers, these insurance losses have important policy implications. More than half of the newly jobless will obtain Medicaid coverage in states that expanded the program under the ACA — but only about one-third will do so in the states that have not expanded Medicaid, according to the Urban Institute.

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Many businesses have tried to keep their workers insured during the pandemic. Companies have relied on federal government aid, such as the Paycheck Protection Program, to pay insurance premiums. Government funding has “prevented the economic crisis from becoming a coverage crisis right away,” said Leemore S. Dafny, a professor at the Harvard Business School. A report that Dafny co-wrote found that nearly a third of small businesses surveyed in late June said they were not sure they could keep paying health care premiums beyond August.

Another option for people who lose their jobs is a program known as COBRA, which stands for the Consolidated Omnibus Reconciliation Act. COBRA is a form of health insurance coverage provided by a company to a former employee for about 18 months. But COBRA can be very expensive, because the former employee also has to pay the employer portion of the plan.

Health policy experts have suggested several options to address the burden of this massive loss of insurance due to COVID-19-prompted layoffs. These include temporarily allowing more federal support for Medicaid in nonexpansion states, expanding the income range for premium subsidies in the insurance marketplaces created by the Affordable Care Act, providing subsidies for COBRA insurance and increasing the federal share of Medicaid funding.

But a cloud of uncertainty hangs over all these proposed solutions. Congress and the Trump administration have had trouble agreeing to a broader economic recovery package; health insurance support is just an element of that. “For the most part, there has not been tangible results to help people get coverage if they have lost it,” says Andrew Schwab, policy director at United States of Care.

Perhaps more ominously, the ACA's fate may hang in the balance. The Supreme Court is scheduled in November to hear a challenge to the law's legality. With the possibility that a sixth conservative justice, Amy Coney Barrett, may be sitting on the court by the time the case is heard, an important backstop in the health insurance market could be disrupted.

All this chaos and change could bolster support for more ambitious and sweeping changes to U.S. health insurance, such as a single-payer system referred to by its proponents as Medicare for All. But while much of the political debate in health care has centered on the future and potential expansion of government programs, employer-sponsored insurance continues to provide the greatest portion of health spending in the nation.

As policymakers, experts, health care providers and consumers consider the options, here are some of the questions they are debating:

Can the employer-based health insurance system survive the COVID-19 pandemic?

Even with millions of people losing their employer-based health care, the insurance companies that power the system do not seem to be suffering financially. Some of the largest, such as Humana, UnitedHealth Group and Anthem, reported second-quarter earnings in August that are double what they were a year ago, largely because in the short term their claims payouts have fallen.

And wealthier people are by and large not the ones feeling the impact of massive health insurance losses due to pandemic-prompted layoffs. “People in white-collar jobs with generous employer sponsored benefits have been largely unscathed,” says Arielle Kane, director of health care at the Progressive Policy Institute, a centrist-Democratic think tank. The people most affected are those in the service and hospitality industries, she says.

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“COVID-19 has had a disparate effect across industries,” Kane says. “This unequal impact means that the same entrenched groups will seek to extend the status quo without considering the impacts it has on more vulnerable groups.”

“For better or worse,” she says, “the employer-based health insurance system is entrenched.”

With more vulnerable groups more likely to have lost their health insurance, the system may naturally move away from being dominated by employer-sponsored health insurance, says Anuj Gangopadhyaya, a research associate in the Health Policy Center at the Urban Institute. Supports are in place for people to obtain insurance during the pandemic through an expanded Medicaid program in some states and through relaxed enrollment opportunities on ACA health plans, which allow unemployed and self-employed people to buy insurance through state marketplace exchanges. People who cannot afford these plans can get tax subsidies, although critics say the subsidies are not enough to make these marketplace plans affordable.

“The system is evolving to the point that employer-sponsored insurance is not the end-all-be-all for coverage” he says. “There are other protections and options, and so even if employer-based coverage falls during a recession, the health insurance system remains resilient.”

One reason for this resilience is because the system is propped up by a lot of government support. Employers have an incentive to provide insurance coverage because they can take a tax deduction for their expenditures for the coverage. In addition, their employees are for the most part not taxed on the value of the benefit. This is the single largest federal tax break, valued at an estimated $242 billion in 2019, according to the Treasury Department. This tax break for employer-sponsored insurance costs the U.S. government more in revenue than the mortgage-interest deduction.28

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Some in the industry argue that more support should be given to keep the system intact. “This crisis will be over — not soon enough — but it will be over, and we need to fundamentally keep that highway back to jobs, and job-provided health care open,” says Ilyse Schuman, senior vice president of health policy for the American Benefits Council, which represents major employers. “That's what Congress needs to do now, and employer- sponsored insurance plays a big role in that.”

In addition, even with a recession and mass job losses, the pandemic may be causing people to reconsider their individual health needs. “In the wake of the SARS epidemic, for example, we saw a temporary spike in critical illness policy sales in Asia,” said Laura J. Hay, global head of insurance at the KPMG International consulting firm, referring to a disease outbreak that began in China in 2003. “We may see a similar phenomenon post-coronavirus, with rising sales of health insurance.”

One reason big insurers are doing so well is because their payments for medical claims have fallen by billions of dollars in recent months as many patients have postponed costly elective surgeries. Some people have avoided doctors' offices and emergency rooms for fear of risking exposure to COVID-19.

Insurers warn, however, that even though they have enjoyed strong profits, the cost of the pandemic could become overwhelming, and employers and workers may not be able to keep paying for coverage.

Insurance companies and employers are pushing Congress to consider helping them pay for the crisis by setting up a reinsurance program that would cover the most expensive medical claims. The government would fund the program to lower the amount being paid by employers and insurers.

Some experts think the big insurance industry profits could shine a spotlight on the inequities in the system that make it unviable. While insurance companies are seeing a windfall, other players in the health care industry are not, the experts say. Many small medical practices and rural hospitals are struggling to stay open. (See Short Feature.)

And analysts say this insurance windfall may not last. “The cost of providing increased COVID-19 coverage to policyholders, coupled with the overall higher frequency and severity of claims to treat the virus and exacerbated by policy cancellations, is expected to have a profound impact on the profitability of the insurance industry,” said Christopher Jackson, a partner at Marcum Accountants & Advisors. “COVID-19 has the potential of increasing future health insurance premiums significantly.”

Some insurers have warned that rates for consumers could increase by as much as 40 percent due to the pandemic. “These increased costs could mean that many … Americans in the commercial market may lose their coverage and go without needed care,” said Peter Lee, the executive director of Covered California, the state insurance marketplace created under the ACA.

Employers are reporting premium rate increases of 3 percent to 4.5 percent for 2021 by major insurers.

In addition, many businesses will face increasing pressure to cut costs — and some of that cost-cutting could come from health care expenses. Some conservative policymakers have been pressing for companies to move away from providing health insurance, and instead offer health reimbursement arrangements, or HRAs, in which employers set aside a fixed amount each year for their employees to use for health expenses or insurance.

“Employers are going to look to HRAs as a potential way to get more certainty over their costs,” said Brian Blase, a former Trump administration health care adviser. “There's no love for traditional employer coverage.”

Has the COVID-19 pandemic increased support for a single-payer system such as Medicare for All?

The decades-long debate in the United States over health care access has often centered on the unique way in which the country relies on employer-sponsored plans. Policymakers have long considered whether a single-payer, government-funded system, which is used in many European countries, would be a better way to provide access.

The issue was a hot topic in the 2020 Democratic presidential primaries, before the pandemic hit. Liberal candidates such as Sens. Bernie Sanders, I-Vt., and Elizabeth Warren, D-Mass., argued that the country should move away from the employer-sponsored system and embrace a single-payer system, which they called Medicare for All. Republicans seized on this proposal as an indication that Democrats wanted to move the country toward socialism.

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Sen. Bernie Sanders, I-Vt., pitches his Medicare for All health care plan in a speech in Washington in 2019. While support for a single-payer plan has grown, the idea has not been a major focus in the final stages of the presidential campaign. (Getty Images/NurPhoto/Cheriss May)

So far, it is unclear whether the pandemic will create a fresh groundswell of support for a single-payer system. In March, in the early stages of the pandemic, support for Medicare for All hit a nine-month high, according to a Morning Consult/Politico survey. In this poll, 55 percent of voters said they supported Medicare for All, the highest level since June 2019.

And in a survey of swing-state voters taken this spring, Republican pollster Whit Ayres asked how the government should help workers who have recently lost insurance coverage. The poll found that 47 percent supported a major government expansion of health care, 31 percent believed the best option for laid-off workers was to go on Medicaid and 16 percent preferred federal subsidies for Obamacare plans.

But the health care debate during the pandemic has not focused on a single-payer system. Former Vice President Joe Biden, who won the Democratic presidential nomination, has opposed Medicare for All. Biden and many congressional Democrats instead favor creating a so-called public option under Obamacare that would compete with private insurers.

Supporters of Medicare for All have attempted to bring it back to the forefront of the national conversation. Sanders and Rep. Pramila Jayapal, D- Wash., introduced a bill in May to expand Medicare to cover all Americans who lack health insurance, but the measure has received little attention.

Some analysts predict demand for a single-payer option will rise after the election. “This is health care moonshot time,” says Irwin Redlener, founding director of the National Center for Disaster Preparedness at Columbia University, who served on the Biden campaign's public health task force earlier this year. “If Joe Biden is elected president, there most certainly will be significant changes proposed in the U.S. health care system,” starting with the public option, he says.

But Kristi Martin, a former senior health adviser to the Obama administration, says that polling data do not reveal widespread support for policy options such as Medicare for All. Polling during the pandemic has not shown “huge movement” in support for a single-payer system, even though “people do want a safety net,” she says.

Indeed, the Kaiser Family Foundation, a nonpartisan health research organization that for years has tracked public opinion on the idea of a national health plan, says polling shows that people support “incremental changes to expand the public health insurance program.”

There has been a shift “toward more receptivity to bigger solutions to both of our biggest problems: coverage and affordability,” said Ezekiel Emanuel, the chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania and a member of Biden's public health advisory committee. “But people's thinking hasn't caught up with the dire situation we're in.”

Don Berwick, who ran the Centers for Medicare and Medicaid Services during the Obama administration, agrees. He says Congress is applying “a whole series of Band-Aids and special measures” to address the problems of those who have lost their insurance during the pandemic. “What if, instead, we just had universal health insurance?” he asks.

Jayapal said attitudes may change if Democrats win control of the White House and the Senate in November. “It's entirely possible that everything shifts on health care, within weeks or months after the election,” she said.

Does employer-based insurance produce better health outcomes?

Proponents of the employer-based system point to situations like that of the Satterfields, the Atlanta couple, in which people are afraid to move to government insurance, as evidence of the superiority of private plans.

“You might want to check out the death rate in France before you think the form of health system [there] is the answer,” Neera Tanden, president of the Center for American Progress, a left-leaning advocacy group, wrote on Twitter as she was debating the merits of a single-payer system.

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In truth, the answer is more complicated, experts say.

Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University's School of Medicine, said that coverage provided by Obamacare plans sold through state health care marketplaces is likely not as good as what an employer provides. He also believes Medicare coverage is inferior to the kind of care available from a job-based plan.

But Medicaid, the federal-state program for lower-income people, provides benefits. This program comes with no out-of-pocket charges for most services, and it covers traditional health care needs.

The Urban Institute's Gangopadhyaya says there are “pros and cons” to government health care, as well as private health care obtained through an employer. There is a range in quality among employer plans, and the ultimate answer depends on the network of doctors and the types of treatment covered by an employer plan, he says: “The truth is ambiguous, and there are no solid answers.”

Caryn Solomon is an elementary school teacher in Maryland who lost her health insurance when she lost her job due to the pandemic. She qualified for Medicaid, but she feels the insurance is not great, because she has to stay within a specific hospital network, and she needs a referral for all her specialists.

Ge Bai, a health policy professor at Johns Hopkins University who studies health markets, says a review of medical literature shows that private insurance plans lead to better health outcomes.

For example, a 2015 study concluded that the quality of care delivered to patients within the same hospital varies by insurance type. “We found that privately insured patients had lower risk-adjusted mortality rates than did Medicare enrollees,” the study concluded. “Medicare patients appeared particularly vulnerable to receiving inferior care.”

More specifically, various studies have found that cancer care is superior with private insurance compared to government insurance. For example, a 2017 report published in the Journal of the American Medical Association concluded that “Medicaid patients were significantly more likely to experience delays in surgery compared with privately insured patients.”

Jean-Pierre Unger, a Belgian public health physician and market researcher, co-wrote a 2019 paper that found a correlation between the high cost of health care and the state of a country's commercial insurance market.

In the study, Unger compared health programs in the United States, Switzerland and the Netherlands. Each of those countries has expanded commercial health insurance since the 1990s. The United States' program has expanded the most and the Netherlands' the least. The United States pays the most for health care and delivers the poorest outcomes among the three countries, while the Netherlands pays the least and delivers the best, the study found.

Each of the three countries' health costs has risen and the quality of care has declined as they have further expanded their commercial insurance markets, according to the study.

Unger says he believes the United States must eventually move toward a public health care program. Competition among private insurers naturally creates secrecy, he says, which makes coordinating a national strategy across a country as large as America even more challenging.

One European country that has excelled in its response to the pandemic, he says, is Germany, which has an active insurance market through a hybrid model; because its public health system is well funded, the government was able to quickly relay information to a large network of primary care physicians.

By comparison, projections indicate that by 2032 the United States will have a “real and significant” shortage of primary care physicians, he says.

It is indisputable that health status is usually better for people with employer-based insurance, but that is “a reflection of income and other social determinants” and not necessarily the nature of their coverage, the Progressive Policy Institute's Kane says.

Moreover, the COVID-19 pandemic has spotlighted that “the systemic racism permeating health care is apparent in the health insurance system,” Martin, the former Obama administration adviser, says. Native Americans, Hispanics and African Americans have the highest rates of being uninsured.

The federal Centers for Disease Control and Prevention reported in July that “people from some racial and ethnic minority groups are more likely to be uninsured than non-Hispanic whites.”

And a 2016 study in the academic journal Population Research and Policy Review found that “health insurance coverage varies substantially between racial and ethnic groups in the United States.”

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Christen Linke Young, a health policy fellow at the Brookings Institution think tank in Washington, said that “there are significant racial disparities in access to health coverage and health outcomes” in the United States. People of color are “far more likely to be uninsured in America,” she said.

But when it comes to treatments for COVID-19, the differences between employer-sponsored and government insurance may not matter that much. Some states are offering COVID-19 testing free of charge. The Families First Coronavirus Response Act, enacted in March, created a state option to extend Medicaid eligibility to the uninsured for COVID-19 testing.

Background Evolution of Employer-Based Insurance

It might seem like the American system of providing health insurance through a job is rooted in the capitalist fabric of the country.

But the system came about during World War II, as a result of wartime wage freezes and tax policies. And “the very idea of health insurance” that began flourishing at that time is “in some ways the original sin” in health care, Elisabeth Rosenthal, a physician and the editor-in-chief of Kaiser Health News, wrote in An American Sickness, her 2017 book examining the system.

Before World War II, there was not a need for health insurance, because there was not much health care to purchase. Americans mainly paid their own way when it came to medical needs. People who worked in dangerous industries had access to company doctors, often in union-run clinics. Until the early 20th century, most Americans did not rely on hospitals for medical treatment.

But with advances in medicine, and antibiotics in particular, medical schools and hospitals grew more sophisticated and medical care became more expensive and more available.

“Hospitals had a financial problem from the very beginning of scientific medicine,” economic historian John Steele Gordon wrote in A Short History of American Medical Insurance. “By their nature they are extremely labor intensive and expensive to operate. Moreover, their costs are relatively fixed and not dependent on the number of patients being served.”

To combat that expense, employers and workers came up with novel ways to manage costs. In 1929, the Dallas school system established sickness insurance to protect teachers against impoverishment. That plan allowed teachers to pay 50 cents a month in exchange for Baylor University Hospital in Dallas picking up the tab on hospital visits. That Dallas plan eventually came to be called Blue Cross. A group of doctors in California later created their own plan in 1939, called Blue Shield. Eventually, people were purchasing Blue Cross for hospital services and Blue Shield for doctors' services. (The two companies merged in 1982.)

So for the first half of the 20th century, most health insurance was bought privately, and it was not a particularly popular product. World War II changed that.

In 1942, with a booming economy and 12 million working-age men in the military, the country was facing a major labor shortage. Economists worried businesses would keep raising salaries to compete for workers and prices would spiral out of control. President Franklin D. Roosevelt signed an executive order that established the Office of Economic Stabilization. The result was a freeze on wages, and therefore businesses were not allowed to use pay increases to attract workers. Health insurance emerged as an alternate incentive.

When the government “froze salaries during and after World War II, companies facing severe labor shortages discovered that they could attract workers by offering health insurance instead,” Rosenthal wrote. “To encourage the trend, the federal government ruled that money paid for employees' health benefits would not be taxed. This strategy was a win-win in the short term, but in the long term has had some very losing implications.”

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Industrialist Henry J. Kaiser, pictured here testifying before a Senate committee in 1950, helped develop an employer-based health coverage plan that attracted some 300,000 enrollees. (Getty Images/Corbis/Hulton-Deutsch Collection)

Indeed, the decision by the IRS in 1943 to exempt employer-based health insurance from taxation made it cheaper to get health insurance through a job than by any other means. A 1954 statute made the tax advantages more appealing by codifying them in law. Participation in health plans grew from 9 percent of the population in 1940 to 63 percent in 1953. By the 1960s, a voluntary health plan covered 70 percent of the population.

During this time, the types of health plans that were available broadened. For example, in 1945, physician Sidney R. Garfield and industrialist Henry J. Kaiser expanded on the concept of prepaid medical care for workers in dangerous industries by introducing their Permanente Health Plan. Within about a decade, the plan's enrollment topped 300,000, due in large part to the support of two labor groups, the International Longshore and Warehouse Union and the Retail Clerks Union.

In 1948, the National Labor Relations Board ruled that health benefits were subject to collective bargaining between labor and management. Companies had no choice but to negotiate with unions about insurance plans, and unions fought hard to get generous plans. Eventually, employees saw health insurance as a basic element of their compensation package. By the mid-1960s, Americans viewed the system in which people with good jobs got health care through work and almost everyone else looked to government as the natural order of things, according to economic historian Melissa Thomasson. And over the years, a phenomenon known as job lock — in which an employee feels unable to voluntarily leave a job that is tied to benefits — took hold in the labor market.

Government Plans

Even with the rise of employer-based plans, some policymakers were looking to create a national health care system. They viewed the company- provided plans as inadequate because so many Americans still lacked coverage.

In 1945, Democratic President Harry S. Truman called for such a system. “In a nation as rich as ours, it is a shocking fact that tens of millions lack adequate medical care,” Truman said in his 1949 State of the Union address. The idea was popular, but the leading business lobbying group, the U.S. Chamber of Commerce, opposed it, as did the American Hospital Association and the American Medical Association. So did many labor unions, which had waged hard fights to win insurance benefits for their members. With opposition coming from many directions, national health insurance suffered the first of its many historical failures.

But Truman's idea persisted. One reason for this was the fact that as employer-sponsored plans became the cornerstone of the health care system, health costs steadily rose and retirees could not afford private coverage.

In homage to his predecessor, Democratic President Lyndon B. Johnson chose Truman's hometown of Independence, Mo., for a 1965 signing ceremony for the most sweeping U.S. health legislation of the 20th century. While smaller in scope than Truman's vision, the law created Medicare for people ages 65 and older and Medicaid for those living in or near poverty.

One reason that the scope for these programs was not larger was because the same forces that fought Truman in 1945 sought to stymie the creation of Medicare and Medicaid, labeling the programs “socialized medicine.” Some of that opposition faded when the programs provided a windfall to the health care industry.

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In the mid-20th century, other developed countries with democratic foundations chose to cover their entire populations through government plans. In 1948, the United Kingdom created the National Health Service, which provided care based on need rather than ability to pay. Canada's federal government in 1966 moved to provide publicly funded medical care insurance plans.

But for a number of reasons, national insurance failed to gain a foothold in the United States. In addition to the opposition from business and medical groups, criticism of a social insurance system dated back to World War II, as a backlash to a method of financing social programs that had originated in Germany.

Over the ensuing decades, presidents from Republicans Richard Nixon and Ronald Reagan to Bill Clinton (a Democrat) tried, with mixed success, to improve the nation's health insurance system. Nixon in 1974 proposed creation of a comprehensive health insurance system, but it failed to win congressional approval. Reagan expanded the role of health maintenance organizations (HMOs) in Medicare. In 1993, Clinton proposed a broad overhaul of the health insurance system, in which most Americans would get their coverage through large regional purchasing groups with employers paying 80 percent of the premiums, but it also failed to pass in Congress.

While none of these presidents achieved their ultimate goals, they scored a few victories. Clinton, for example, signed a law in 1997 that created the state-federal Children's Health Insurance Program (CHIP). The program was intended to secure medical care for children in families with too much income to qualify for Medicaid but too little to afford private insurance. (As of July 2020, 6.7 million children were enrolled in CHIP.)

The Rise of Insurance Companies

After World War II, Blue Cross and Blue Shield were the only major insurers. They operated as nonprofits and accepted everyone who signed up. However, rising demand for insurance and more expensive medical care led to a proliferation of insurance products.

“For-profit insurance companies moved in, unencumbered by the Blues' charitable mission,” Rosenthal wrote. “They accepted only younger, healthier patients on whom they could make a profit. They charged different rates, depending on factors like age, as they had long done with life insurance. And they produced different types of policies, for different amounts of money, which provided different levels of protection.” Eventually, the Blue Cross Blue Shield structure could not compete, and they became for-profit insurers. “This was the final nail in the coffin of old-fashioned noble-minded health insurance,” Rosenthal said.

The biggest change to the system since the creation of Medicare and Medicaid came in 2010 when President Barack Obama signed the Affordable Care Act.

President Barack Obama signs the Affordable Care Act into law in 2010, surrounded by Democratic lawmakers. Vice President Joe Biden, now the Democratic presidential nominee, is second from the left. (Getty Images/Win McNamee)

Among its many changes, the law mandated that insurance marketplaces begin operating in every state. The system allowed people who could not get employer-sponsored coverage to shop for coverage in so-called state exchanges. The law also provided many people with subsidies that helped pay for coverage. In addition, it made it easier to obtain health insurance through Medicaid. After the ACA went into effect, the number of uninsured people dropped by 20 million between 2010 to 2016.

But the system contained many quirks and flaws. The shortcomings, along with fervent Republican opposition, kept the law from achieving its vision of helping to make sure all Americans have health insurance.

A chronic problem with the marketplace system was that consumers complained the coverage offered through it was not affordable, with or without subsidies.

The law has been under attack since its inception. For example, not all states supported the expansion of their Medicaid programs, some for ideological reasons and some because they feared they would eventually be saddled with higher costs. While the expansion was meant to be national, a 2012 Supreme Court ruling made it optional for states. Before the pandemic, 14 states had not expanded their programs.

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And Republicans have sought for years to eliminate the law through legislative and judicial action. Their goal, they said, is to “repeal and replace” the ACA with a plan that will be more affordable and cover more people, although they have yet to offer a concrete alternative. Their biggest legislative victory came in the early months of Trump's presidency when the Republican-controlled House narrowly approved a bill to repeal and replace the law. But the legislation failed to pass in the Senate.

Other steps Republicans have taken to undermine Obamacare include regulatory changes and delays, funding cuts, elimination of low-income subsidies and a parade of lawsuits.

Most significantly, Republican officials in 20 states filed a suit in 2018, with the backing of the Trump administration, seeking to have the entire law struck down.

That lawsuit has made its way through the judicial system and is scheduled to be heard by the Supreme Court a week after the Nov. 3 presidential election. The case will mark the third time that the Supreme Court takes up a significant dispute over the Affordable Care Act.

Current Situation Threatened Coverage

The pandemic is changing the politics and pressures related to the nation's employer-sponsored health insurance system.

Attorney General William Barr, a Trump loyalist, had urged the administration a few months into the pandemic to modify its position on the ACA case before the Supreme Court. Barr argued that, in light of COVID-19, the administration should not argue that the entire law be struck down. But the administration is still moving forward, having joined a case out of Texas that seeks to invalidate the law.

Amid this uncertainty, lawmakers and regulators are considering a variety of steps to bolster people's health insurance coverage.

Many states have extended their special enrollment periods in which people can join Obamacare plans that are sold on state marketplaces. Typically, these plans are open for enrollment only in the final months of the year.

Regulations have also been changed to make it easier for people to obtain health insurance. A new federal rule in July gave people significantly more time to decide whether to hold onto their employer-sponsored health insurance through COBRA after they have been laid off or furloughed from a job.

Separately, a group of unions, big insurers, hospitals and a consumer advocacy group have joined together to lobby Congress to subsidize COBRA premiums through a new economic stimulus package. House Speaker Nancy Pelosi, D-Calif., has supported COBRA subsidies as part of a pandemic relief package. But critics of this approach say COBRA plans tend to help middle- and higher-income people, not the retail and service industry workers who are most affected by pandemic-prompted job losses.

“Almost no matter the employment outlook or time horizon, COBRA subsidies are unlikely to be the most cost-effective way of expanding coverage or relieving financial hardship,” said Matt Fiedler, former chief economist of the White House Council of Economic Advisers during the Obama administration. “They're just not targeted on the right people.”

Other ideas for health insurance support that have been proposed in Congress include a measure to subsidize employer premiums for laid-off or furloughed workers. The Trump administration, for its part, prefers to address health insurance losses by covering treatments for uninsured coronavirus patients through hospital bailout funds as part of a pandemic relief package.

In addition, many major insurers, including Anthem, have waived copays and given members money back through premium rebates.

Anthem, whose headquarters in Woodland Hills, Calif., is seen here, and other

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major health insurers have given some subscribers premium rebates and waived some copays on doctor visits during the COVID-19 pandemic. (Getty Images/Dadid McNew)

And in some states, voters are taking matters into their own hands.

Voters in the Republican-leaning states of Missouri and Oklahoma this summer approved ballot initiatives to open Medicaid eligibility to some healthy adults.

The successful ballot initiatives on Medicaid expansion have been part of a grassroots campaign by liberal activists. The initiatives have extended Medicaid eligibility to about 1 million low-income Americans living in states where governors or legislatures oppose expanding the program.

But in some states, the pandemic has disrupted plans to widen Medicaid. Kansas shelved a plan to expand Medicaid coverage to about 150,000 people in the state, and in California, Democratic Gov. Gavin Newsom scrapped a proposal to extend coverage to 27,000 elderly undocumented immigrants due to a $54 billion shortfall in the state budget because of the pandemic.

Other states have tried to create a public option that would help insure more people, but the pandemic has stalled those efforts as well. The Colorado Legislature scrapped votes on a bill to create such a public option (as well as a paid family-leave bill) because consumers, health care providers and others would not be able to participate in the process due to the pandemic. Washington state also scaled back the launch of a high-profile public option for the fall, saying it was not the time to do so when the coronavirus is overwhelming hospitals and health insurance companies.

2020 Politics

The inability of some pioneering states to launch a public option due to the pandemic comes as Democratic nominee Biden has made a federal public option a centerpiece of his health care plan. He is proposing that the 2 million people who cannot get health care coverage because their states have not expanded Medicaid be automatically enrolled in the new public option plan at no cost.

Under Biden's proposal, some 12 million people who get insurance through their jobs could find the public option to be a cheaper alternative, according to Kaiser Family Foundation estimates.

Other steps Biden has proposed include expanding premium tax subsidies so people could pay for a more generous plan and more people would qualify for the subsidies. People who are currently ineligible for government assistance could see their monthly premiums drop by half under this proposal. Biden estimates that 97 percent of Americans would have health insurance if his plan is adopted.

Trump, for his part, has announced his intention to protect people with pre-existing conditions, though he has offered no details. That vow contradicts regulatory changes he has made throughout his presidency that make it easier for insurance companies to sell plans that exclude patients with pre-existing conditions.

Supreme Court Challenge

The Supreme Court is scheduled to hear arguments on Nov. 10 in a suit that seeks to invalidate the Affordable Care Act. California v. Texas could end the law completely if the court rules in favor of 20 Republican-led states and the Trump administration.

The death in September of Justice Ruth Bader Ginsburg means the Supreme Court will have a smaller liberal wing when it hears this challenge to the law. Trump's nominee to replace Ginsburg, appeals court Judge Amy Coney Barrett, has criticized the high court's 2012 decision to uphold the ACA.

As the Senate considers the nomination of Judge Amy Coney Barrett to the Supreme Court, Democratic senators display photos of people who they say

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would be harmed by the disappearance of the ACA. The Supreme Court is due to hear arguments in November on a suit that seeks to eliminate the act. (Getty Images/Drew Angerer)

Democrats face long odds of blocking Barrett's confirmation but hope the threat of invalidating the law will motivate voters in the upcoming election. A vow to protect Obamacare helped Democrats recapture control of the House of Representatives in 2018, after Republicans in Congress had moved closer to repealing it.

Despite the pandemic's impact, health care was not, until recently, a top concern for voters in the 2020 elections. A poll in early September by the Kaiser Family Foundation found that only 10 percent of registered voters viewed health care as the most important issue in determining their vote for president. An NBC/Wall Street Journal poll conducted before Ginsburg's death found that 24 percent of voters viewed health care as a top issue, compared with 40 percent who selected the economy.

Outlook Telemedicine Growth

Even as steps are taken to preserve the employer-based system and ensure people have health insurance during the pandemic, some industry experts believe changes made to the system — some necessitated by COVID-19 — may make health insurance less vital in coming years.

During the pandemic, medical care has moved away from the traditional in-the-office-with-a-doctor model. Chris Jennings, a former health care adviser to Presidents Clinton and Obama, said that because of COVID-19, telemedicine “has probably been accelerated by a decade.”

Insurers have helped support that trend by waiving telehealth fees and deductibles. Seven months in, though, some companies moved to end that waiver if the appointments are not related to COVID-19. And Medicare coverage for many telehealth services is scheduled to end after the pandemic.

But telehealth has proven popular, and Congress could pass legislation to make Medicare support for it permanent. “Reversing course would be a mistake,” said Seema Verma, who oversees Medicare as administrator of the Centers for Medicare and Medicaid Services.

Some industry analysts are pressing for other changes to the system to make health insurance less vital. Unger, the Belgian professor, says nurses could be providing more treatment to fill gaps in availability, especially in rural regions and the Southeast, where lawmakers have generally declined to expand Medicaid to the working poor. The American Medical Association (AMA) has tried to block laws that would allow nurses to fill more gaps in the delivery of medical care.

To Unger, a key flaw in the U.S. health insurance system is its reliance on competition. The AMA's effort to thwart nurses from meeting the demand for basic health care is one aspect of how antithetical competition is to good health care, he says.

Perhaps if premiums rise, companies will be more likely to support a single-payer system, Unger says. To pay those high premiums, companies have to raise the prices they charge their customers, lowering their competitive advantage in the global marketplace.

Johns Hopkins' Bai predicts that instead of investing in a full-blown public option, the nation will be better served by having the free market fill in primary health care via telehealth, or through one-stop-shopping clinics in pharmacies.

Indeed, CVS, Walmart and Walgreens are developing competing visions for making basic health care cheaper and more accessible. Those visions could involve cutting out insurance completely, using a combination of a direct primary care model, which is subscription-based and involves a doctor or a nurse, and technology for routine and well-studied ailments such as strep throat.

The government must force price transparency for the free market to work, Bai says, and provide subsidies to financially disadvantaged populations. And it must invest more in public health, where the free market will fail.

“If we don't make meaningful improvements in our private sector using market forces, then a tipping point will come, and we will be in crisis and people will pursue a government-controlled system,” Bai says. “By that time, we will have enough political will.”

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Pro/Con Can the current insurance system survive the COVID-19 pandemic?

Pro Ilyse Schuman Senior Vice President, Health Policy, American Benefits Council. Written for CQ Researcher, October 2020

The past six months have wrought the perfect storm of a public health and economic crisis, brought upon by the COVID-19 pandemic. Some see this storm as a reason to dismantle employer-sponsored health coverage and replace it with Medicare for All. Concern about the intersection of a public health crisis with widespread unemployment is certainly understandable, but we cannot let the tempest obscure the fact that employer-sponsored coverage is now more important than ever.

Skeptics of employer-sponsored coverage are aiming their criticism in the wrong direction. The Affordable Care Act was built on the foundation of employer coverage, supplemented by Medicare, Medicaid and a robust individual market. But state budgets are buckling under the financial pressures of the pandemic, and the federal government has not taken the necessary steps to shore up the individual market. The short-term solution is to provide temporary COBRA subsidies so laid-off or furloughed workers can afford to stay on their employer plans. The long-term solution is to strengthen the individual market.

At the heart of this debate is the notion of “value.” Because employers excel at creating value through innovation and market pressure, job- based health coverage has become synonymous with the high-quality coverage that people want to keep.

Employers, already at the forefront of strategies to lower costs and improve quality before the pandemic, will be even more important in the drive for value afterward. Policymakers should promote this innovation by improving transparency, addressing market failures and realigning incentives to reward providers based on the value of care rather than volume.

Employer sponsorship also delivers value for the government and taxpayers. For every dollar attributable to the government's tax incentives for employer coverage, employers spend $4.45 on health benefits. It would cost the federal government much more to pay for the same level of health care directly through Medicare for All. In a nationwide poll during the 2018 election, voters said they trusted employers more than any other source for high-quality health care coverage.

This storm shall pass. When it does, we will look back at the critical role employer-sponsored health coverage played in helping us navigate the crisis and how it can continue providing lower-cost and higher-quality health care, protecting working families in the next crisis.

Con Emily Barson Executive Director, United States of Care. Written for CQ Researcher, October 2020

Our antiquated health insurance system — in which most people receive health coverage from their job — increasingly fails to meet people's needs. It is also very costly for both private- and public-sector employers. We believe our country needs to rethink how we do this.

COVID-19 has heightened awareness of the flaws in our existing system, and people want to take this opportunity to improve it. What we hear in our conversations with people is that the challenges of COVID- 19, combined with the alarming racial disparities it has laid bare, have refreshed the imperative to strengthen our health care system. People are worried that they cannot depend on their insurance when they need coverage, especially given the historically high number of people who have simultaneously lost both their jobs and health security.

Our country's 75-year-old paradigm connecting our jobs to our health insurance is tremendously precarious. Even before the pandemic, the employer health insurance tax deduction was expensive and regressive. For at least the past two decades, the system has been extremely costly for both businesses and employees, leaving about a quarter of people with insurance potentially unable to cover costs. These shortcomings stifle innovation and entrepreneurship via “job-lock,” and there is also evidence that loss of job-connected health insurance widens racial disparities.

What the pandemic is showing us is, when a disease ravages both people's health and the economy, millions are left exposed to inadequate care at a time when the health of one person is linked to the health of us all.

Insurance is about financial security. Decoupling health coverage from one's job would prevent the loss of health coverage at the same time one loses a livelihood. It would also free employers — most of whom are not health care benefits experts — from the expensive and time- intensive efforts of administering health coverage. That is why employers are a crucial part of how we will bridge the interconnectivity of work, economic downturns, pandemic response and health.

To explore this, United States of Care (USofCare) released a paper examining approaches utilized by states and leading private companies to control the costs straining the system. In the coming months, USofCare will convene policy experts, employers, innovators and people experiencing our health care system to understand what works and what alternatives could look like. We hope you will join us in this effort.

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https://www.americanbenefitscouncil.org/pub/?id=16E9BBE3-9B27-D7AA-EC7C-E9F86419C786

https://www.americanbenefitscouncil.org/pub/?id=B949F447-F1CA-4DD0-817A-A7E96D8E3BFC

https://www.americanbenefitscouncil.org/pub/?id=BCEEF8FB-EFA1-AB7F-17A8-4483226A5129

https://unitedstatesofcare.org/covid-19/a-system-under-stress-exacerbated-the-employer-sponsored-health-insurance-system-at-a-crossroads/

https://unitedstatesofcare.org/covid-19/guide-humanizing-health-care-debate-covid-19-response/

https://abcnews.go.com/Health/wireStory/side-insurance-health-insurance-66471815

https://www.cbsnews.com/news/health-insurance-coronavirus-pandemic-12-million-lost-employer-sponsored/

https://www.nytimes.com/2017/09/05/upshot/the-real-reason-the-us-has-employer-sponsored-health-insurance.html

https://www.treasury.gov/resource-center/tax-policy/Documents/Tax-Expenditures-FY2019.pdf

https://khn.org/morning-breakout/cost-of-job-based-health-insurance-premiums-exceeds-20000-tightly-pinching-workers-wallets/

https://www.healthcaredive.com/news/a-quarter-of-adults-in-employer-plans-are-underinsured-commonwealth-fund-s/584918/

https://www.aarp.org/content/dam/aarp/ppi/2015-03/JobLock-Report.pdf

https://tinyurl.com/y5r8w68z

https://www.epi.org/publication/health-insurance-and-the-covid-19-shock/

https://unitedstatesofcare.org/covid-19/a-system-under-stress-exacerbated-the-employer-sponsored-health-insurance-system-at-a-crossroads/

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Chronology 1900–1954 Health insurance emerges in the United States.

Early 1900s With advances in medicine, hospitals transform from a place to die to a place to get treated and cured. The cost of treating patients grows along with the increase in hospitals.

1929 Texas schoolteachers arrange for Dallas' Baylor Hospital to provide room, board and specified services at a predetermined monthly cost — a forerunner of modern health insurance.

1940s Enrollment campaigns seek to boost participation in a new kind of insurance, Blue Cross plans, which involve prepayment for medical care.

1942 President Roosevelt establishes a National War Labor Board that grants him the power to freeze wages, which helps foster the growth of health insurance plans as employers seek ways to attract scarce workers.

1943 The IRS rules that health insurance provided by employers is not taxable income.

1945 President Harry S. Truman, a Democrat, makes an unsuccessful bid to enact a national government health insurance program.

1948 The British government creates the National Health Service, which provides free universal medical care.

1954 Congress codifies the tax exemption for employer-sponsored insurance after the IRS in 1953 revisited its previous decision on the tax break.

1965–1997 Government's role in health insurance expands.

1965 Democratic President Lyndon B. Johnson signs legislation that creates Medicare, which provides health insurance for the elderly, and Medicaid, an insurance program for low-income adults.

1966 Canada's federal government moves to provide publicly funded medical insurance plans, splitting costs with the nation's provinces and territories.

1974 Republican President Richard Nixon proposes comprehensive health insurance, including federal and state assistance for those unable to afford such coverage. Congress takes no significant action toward establishing such a plan during his administration.

1985 Congress passes the Consolidated Omnibus Budget Reconciliation Act (COBRA), which provides for continuing group health insurance for employees after a job loss.

1993 Newly elected Democratic President Bill Clinton offers a plan to overhaul the U.S. health care system. The proposal calls for universal coverage and government control of costs and premiums, with insurers competing to provide coverage. The following year, it dies in Congress due to lack of support.

1997 Congress approves the Children's Health Insurance Program, providing coverage for children in families who earn too much to qualify for Medicaid but too little to afford private insurance.

2010–Present Obamacare opens new era for U.S. health insurance.

2010 Democratic President Barack Obama signs the Affordable Care Act (ACA), soon dubbed Obamacare, which mandates all Americans to have health insurance, creates government-run insurance marketplaces, offers subsidies to some consumers, bars insurers from denying coverage to people with pre-existing medical conditions and offers money to states to raise income limits for Medicaid.

2012 The U.S. Supreme Court finds the ACA's insurance mandate to be constitutional, but rules against the law's provision for mandatory Medicaid expansion by the states.

2017 At the urging of Republican President Trump, congressional Republicans try to repeal the ACA but are unsuccessful. Congress does eliminate the ACA's financial penalty on those who fail to buy insurance.

2018 Republican state attorneys general and governors challenge the ACA's legality, arguing the ending of the financial penalty invalidates the entire law. U.S. District Judge Reed O'Connor declares the ACA invalid, setting up the potential for another Supreme Court decision on the law.

2019 Several Democratic presidential candidates call for Medicare's expansion; some favor creation of a single-payer health system with almost no private insurance…. COVID-19 emerges in China late in the year and soon spreads across the globe, infecting millions, killing hundreds of thousands, shutting down businesses and schools and sparking an economic recession.

2020 Authorities confirm the first U.S. case of COVID-19, in Washington state (January)…. As COVID-19 spreads, states

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implement lockdowns and restrictions, leading to the worst U.S. recession since the 1930s, with more than 30 million unemployed (March)…. States that run Obamacare marketplaces alter their open enrollment periods to allow more people to purchase plans (March-September)…. Voters in the Republican-dominated states of Missouri and Oklahoma approve Medicaid expansions (July-August)…. Supreme Court Justice Ruth Bader Ginsburg dies, and President Trump nominates federal appeals court Judge Amy Coney Barrett to fill the vacancy. A Republican majority in the Senate all but guarantees that she will be confirmed, putting the outlook for the Affordable Care Act in question when the Supreme Court takes it up (September).

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Short Features

Rural Hospitals Face Pressures from COVID-19

“They simply are not financially positioned to face a global pandemic.”

John Henderson spent 16 years running the small rural hospital in his hometown of Childress, Texas. Now a lobbyist for rural community hospitals, he has been taken to unexpected places by the pandemic. Rather than hosting webinars or meeting state lawmakers, Henderson is driving across the border to Mexico to get more hand sanitizer and facemasks for the hospitals in his network.

“What we're seeing is a really uneven and unpredictable display of COVID cases in rural counties and hot spots across the state,” he said. His goal is “to do whatever it takes to help these little rural hospitals survive.”

Rural hospitals are facing unique financial pressures due to COVID-19. They have long operated on thin margins, with high-profit procedures such as elective surgeries keeping them in business. But to deal with the pandemic, they have had to add more beds in case of a surge in patients and buy more ventilators and personal protective equipment — investments that many can ill afford.

“Rural hospitals are designed for primary care and elective surgery,” says Alan Morgan, chief executive officer of the National Rural Health Association. “They simply are not financially positioned to face a global pandemic.”

Rural hospitals tend to have lower amounts of cash on hand and are more likely to be spending more than they are making on a monthly basis, said Lisa Davis, director of the Pennsylvania Office of Rural Health. “So they've been struggling traditionally,” she said. “Then, a pandemic like COVID-19 comes along and they need to essentially pivot on a dime and close down service lines that tend to bring in revenues such as surgery, outpatient services, emergency departments. They don't have the economies of scale to be able to rely on other sources of revenue.”

Since 2010, 132 rural hospitals have closed, according to Morgan. Fifteen of those closures occurred this year. At least 450 more, amounting to 21 percent of all rural hospitals, are at risk, according to the Chartis Center for Rural Health, a private analytics firm.

Paul Nusbaum, former president of the Rural Community Hospitals of America, speaks during a rally by the National Rural Health Association at the U.S. Capitol in 2015. Some 132 rural hospitals have closed in the past decade and another 450 are at risk. (Getty Images/CQ Roll Call/Al Drago)

Twenty percent of the U.S. population lives in rural areas, and residents of these places tend to be older individuals with more chronic conditions, says Dr. Joanna Hart, an assistant professor at the University of Pennsylvania's Perelman School of Medicine. They are also more likely to be underinsured — or uninsured.

The finances of rural hospitals differ from the bigger research institutions that dominate urban centers. The rural facilities serve a smaller share of patients with employer-provided insurance and higher numbers of patients who are uninsured or covered by Medicaid or Medicare. These programs offer much lower reimbursement rates than private insurance.

In addition, people in rural areas are also more likely than their urban counterparts to bounce back and forth between Medicaid eligibility and commercial insurance coverage based on their fluctuating income. This frequent switching often leaves coverage gaps. And almost 14 percent of people under age 65 living in rural areas had no insurance at all in 2017, the most recent year for which data are available, according to the U.S. Centers for Disease Control and Prevention.

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For that reason, many policymakers are pushing for expanded Medicare and Medicaid reimbursement for hospitals. Sen. Amy Klobuchar, a Minnesota Democrat and an advocate for policies that benefit rural areas, wants to allow rural hospitals to eliminate inpatient care without losing their Medicare eligibility.

Morgan, of the National Rural Health Association, says the coronavirus relief measure passed by Congress in March directly allocated funding to rural hospitals. That money was meant to be a bridge at a time when there were hopes that the virus would retreat during the summer months. When that did not happen, “rural hospitals never had the respite they needed,” he says. “The balance sheet for many looks terrible now going into the fall.”

Some rural hospitals have received loans from Medicare to help sustain them during the pandemic, but people in the industry say those loans are now falling due at a time the hospitals really need more help. More than 65 percent of the rural hospitals took Medicare loans when they were available at the start of the pandemic.

For instance, David Usher, chief financial officer for a 12-bed hospital in rural Kansas, said COVID-19 cases have been increasing in his area at a time that he is expected to repay a $1.7 million loan meant to help deal with the pandemic. He wants to use the money to outfit some rooms with negative air pressure to keep contagious patients away from the rest of the hospital, but he is due to repay the loan, which falls due 120 days after it is made.

“It's great having” the funds, he said. “But if I don't know how much I get to keep, I don't get to spend the money.”

— Holly Rosenkrantz

[1] “Rural hospitals were already struggling. Then the coronavirus hit,” PBS NewsHour, May 4, 2020, https://tinyurl.com/yyskro7t.

[2] Adrian Diaz, Karen R. Chhabra and John W. Scott, “The COVID-19 Pandemic And Rural Hospitals — Adding Insult To Injury,” Health Affairs, May 3, 2020, https://tinyurl.com/y4bwrefy.

[3] Hoag Levins, “Already in Fiscal Crisis, Rural Hospitals Face COVID-19,” Penn Leonard Davis Institute of Health Economics, June 2020, https://tinyurl.com/y2eh6be8.

[4] “Understanding the Performance of the Rural Health Safety Net,” Chartis Center for Rural Health, https://tinyurl.com/yym99gon; “As Rural Hospital Closure Crisis Deepens, New Research from The Chartis Center for Rural Health Reveals Scope of Hospitals Vulnerable to Closure,” press release, Associated Press Business Wire, Feb. 11, 2020, https://tinyurl.com/y6pxtxjp.

[5] Eric Lopez et al., “How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature,” Kaiser Family Foundation, April 15, 2020, https://tinyurl.com/y6yyb83z.

[6] David Shelton, “Rural hospitals look for cash flow solutions,” MedCity News, Sept. 27, 2020, https://tinyurl.com/y2lkyw3p.

[7] Ibid.

[8] Sarah Jane Tribble, “Rural Hospitals Teeter on Financial Cliff as COVID Medicare Loans Come Due,” Kaiser Health News, Sept. 22, 2020, https://tinyurl.com/y2mayjwz.

[9] Ibid.

Pandemic Accelerates Medicare's Funding Woes

“We are facing an unprecedented health care financing challenge.”

Backers of a single-payer health insurance system like to call their plan Medicare for All, seeking to build on the popularity of the federal government's insurance plan for those ages 65 and older. And they hope the COVID-19 pandemic will boost support for their proposal.

But Medicare in its current form is running out of money — and the pandemic is only worsening the problem.

Medicare's funding comes largely from a 1.45 percent payroll tax paid by both employers and employees. But the massive job losses caused by the pandemic — more than 22 million at the peak of the shutdowns in March and April — have caused a dramatic drop in the amount of cash coming into the program. And Congress exacerbated the funding problem by dipping into Medicare's reserves to help pay for COVID-19 relief in the spring.

In the pandemic's early stages, Medicare trustees reported that the program's trust fund, which pays for hospital and other inpatient care, would start to run out of money in 2026 — the same projection they gave in 2019. The trustees warned their projections did not include the impact of COVID-19 on the trust fund.

David Shulkin, a former undersecretary for health at the Veterans Affairs Department and head of the department for a year under President Trump, projected in July that Medicare would become insolvent in 2022 or 2023 due to the pandemic. That projection relied on estimates on the number of workers and businesses that would not be contributing the payroll taxes that fund the program because of the pandemic-induced recession.

“We are facing an unprecedented health care financing challenge,” he said. “Time is running short.”

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The Committee for a Responsible Federal Budget, a private fiscal watchdog group, projects Medicare's shortfall will happen in 2023 or 2024 due to the pandemic. “Perhaps more troubling than earlier depletion dates is the time lost by not addressing solvency over the last decade,” the committee wrote in its projection. “Lawmakers will only have a year to address the Medicare shortfall.”

It is not yet clear how the increased health care spending during the pandemic by those covered under Medicare is affecting the program's budget. COVID-19 is hitting older Americans especially hard, and coronavirus-related hospital expenses for those on Medicare are expected to be substantial. But Medicare reimbursements for other types of medical care have fallen during the pandemic, because many hospitals had stopped doing elective procedures. And some older Americans chose to avoid hospitals out of fear of being exposed to the virus.

Congress added to the program's financial woes when it took at least $60 billion from the Medicare Trust Fund — about 30 percent of its total balance — to help finance a provision of the Coronavirus Aid, Relief and Economic Security (Cares) Act in March. The money was used to provide accelerated Medicare payments to hospitals to cushion the impact of the revenue lost from the drop in elective procedures.

One issue that could further accelerate Medicare's financial problems: Trump has called for making permanent cuts to the Medicare payroll tax if he is re-elected. That vow prompted the National Committee to Preserve Social Security and Medicare, a private advocacy group, to endorse Trump's Democratic opponent, Joe Biden; it was the first time the group backed a presidential candidate.

David Shulkin, then secretary of Veterans Affairs, testifies before a House committee in 2018. Shulkin says Medicare, the federal program that provides health insurance to those age 65 and older, could be insolvent as early as 2022 because of the financial stresses caused by the COVID-19 pandemic. (Getty Images/Alex Wong)

Political analysts, though, say it is unlikely that a payroll tax cut would ever make it through Congress.

“I don't see any way that that would gain traction with a significant number of members of Congress,” said Shai Akabas, director of economic policy at the Bipartisan Policy Center, a Washington think tank. “Even if the president decides to push that aggressively, I just don't see that being a realistic part of any package in the near future.”

— Holly Rosenkrantz

[10] Julie Rovner, “Another Problem on The Health Horizon: Medicare Is Running Out of Money,” NPR, July 21, 2020, https://tinyurl.com/y4agg4dh; Juliette Cubanski, Tricia Neuman and Meredith Freed, “The Facts on Medicare Spending and Financing,” Kaiser Family Foundation, Aug. 20, 2019, https://tinyurl.com/y38npxqj; and Jeffry Bartash, “The U.S. has only regained 42% of the 22 million jobs lost in the pandemic. Here's where they are,” MarketWatch, Aug. 7, 2020, https://tinyurl.com/y5mcum58.

[11] “2020 Annual Report of The Boards of Trustees Of The Federal Hospital Insurance And Federal Supplementary Medical Insurance Trust Funds,” Centers for Medicare & Medicaid Services, April 22, 2020, https://tinyurl.com/yygmsp75.

[12] David J. Shulkin, “Medicare's Insolvency Problem Just Got A Lot Worse,” The Shulkin Blog, July 7, 2020, https://tinyurl.com/y6584sqr.

[13] Ibid.

[14] “Updated Budget Projections Show Fiscal Toll of COVID-19 Pandemic,” Committee for a Responsible Federal Budget, June 24, 2020, https://tinyurl.com/y2ubztsz.

[15] Rovner, op. cit.

[16] Ibid.

15 16

18 19

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[17] Juliette Cubanksi et al., “Medicare Accelerated and Advance Payments for COVID-19 Revenue Losses: More Time to Repay,” Kaiser Family Foundation, Oct. 8, 2020, https://tinyurl.com/y27w94a8.

[18] Robert Laszewski, “Trump Calls for Making Permanent Cuts to Both Medicare and Social Security Payroll Taxes,” Forbes, Aug. 9, 2020, https://tinyurl.com/y6eoufon.

[19] Lorie Konish, “Here's what Trump's payroll tax plan may mean for the future of Social Security,” CNBC, Sept. 22, 2020, https://tinyurl.com/y368smzj.

[20] Ibid.

Bibliography Books

Field, Marilyn J., and Harold T. Shapiro , eds., Employment and Health Benefits: A Connection at Risk , National Academies Press, 1993. This book-length report by the Institute of Medicine and the U.S. Committee on Employment-Based Health Benefits examines the strengths and limitations of the employer-based health insurance system, using data to help understand the historical and economic dynamics that have shaped the system.

Ford Chapin, Christy , Ensuring America's Health: The Public Creation of the Corporate Healthcare System, Cambridge University Press, 2015. An economic historian explains why an insurance system created in the 1930s continues to drive health care costs and quality issues today.

Makary, Marty , The Price We Pay: What Broke American Health Care — And How to Fix It , Bloomsbury Press, 2019. A Johns Hopkins University health policy expert details the array of challenges facing the U.S. health care system.

Murray, John E. , Origins of American Health Insurance: A History of Industrial Sickness Funds , Yale University Press, 2007. An economics professor at the University of Toledo describes how the U.S. came to have its distinctive workplace-based health insurance system.

Rosenthal, Elisabeth , An American Sickness: How Healthcare Became Big Business and How You Can Take It Back , Penguin Books, 2017. In this investigation of the reasons behind spiraling health care costs, a journalist and physician offers a detailed look at how insurers, hospitals and pharmaceutical companies have dramatically increased profits.

Articles

Abelson, Reed , “Major U.S. Health Insurers Report Big Profits, Benefiting From the Pandemic,” The New York Times, Aug. 5, 2020, https://tinyurl.com/y3c2kfhb. Some of the largest health insurers saw their second-quarter earnings double from last year.

Facher, Lev , “9 ways Covid-19 may forever upend the U.S. health care industry,” Stat, May 19, 2020, https://tinyurl.com/y8c2rylp. Policy experts predict the pandemic will help end employer-based health insurance.

Kliff, Sarah, and Margot Sanger-Katz , “Without Ginsburg, Supreme Court Could Rule Three Ways on Obamacare,” The New York Times, Sept. 21, 2020, https://tinyurl.com/y5k5h9yf. Despite the death of liberal Justice Ruth Bader Ginsburg, the Supreme Court might uphold the Affordable Care Act.

Reports and Studies

Bivens, Josh, and Ben Zipperer , “Health insurance and the COVID-19 shock: What we know so far about health insurance losses and what it means for policy,” Economic Policy Institute, Aug. 26, 2020, https://tinyurl.com/y4mdfo4m. Two economists argue that COVID- 19 has laid bare the downside of an employer-based health insurance system, and that breaking the link between access to health insurance and a specific job should be a long-term policy priority.

Collins, Sara R. , et al., “An Early Look at the Potential Implications of the Covid-19 Pandemic for Health Insurance Coverage,” Commonwealth Fund Health Care Poll, June 23, 2020, https://tinyurl.com/y9o3xdhu. This study quantifies insurance and job losses due to COVID-19 and finds that furloughing employees rather than laying them off has given the employer-based insurance system some stability during the recession.

Gangopadhyaya, Anuj, Michael Karpman and Joshua Aarons , “As the COVID-19 Recession Extended into the Summer of 2020, More Than 3 Million Adults Lost Employer-Sponsored Health Insurance Coverage and 2 Million Became Uninsured,” Urban Institute, Sept. 18, 2020, https://tinyurl.com/y5boeoce. A study by a think tank uses data from the U.S. Census Bureau to show that the number of uninsured increased in 2020 because of the pandemic and recession.

Garrett, Bowen, and Anuj Gangopadhyaha , “How the COVID-19 Recession Could Affect Health Insurance Coverage,” Urban Institute, May 4, 2020, https://tinyurl.com/y8p73b37. An Urban Institute report predicts that an estimated 25 million to 43 million people could lose their employer-sponsored health insurance because of the pandemic.

Pines, Jesse M. , “COVID-19, Medicare for All, and the Uncertain Future of Emergency Medicine,” Annals of Emergency Medicine, June 24, 2020, https://tinyurl.com/y466whbs. A professor of emergency medicine at George Washington University looks at the possible effect of a single-payer Medicare for All program on payments to emergency doctors and costs for emergency room visits, and concludes that it would increase payments to doctors and reduce costs to patients.

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http://worldcat.org/search?q=ti:Employment+and+Health+Benefits:+A+Connection+at+Risk

http://worldcat.org/search?q=ti:The+Price+We+Pay:+What+Broke+American+Health+Care+-+And+How+to+Fix+It

http://worldcat.org/search?q=ti:Origins+of+American+Health+Insurance:+A+History+of+Industrial+Sickness+Funds

http://worldcat.org/search?q=ti:An+American+Sickness:+How+Healthcare+Became+Big+Business+and+How+You+Can+Take+It+Back

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The Next Step Affordable Care Act

Chotiner, Isaac , “How Amy Coney Barrett Could Affect the Future of the Affordable Care Act,” The New Yorker, Oct. 14, 2020, https://tinyurl.com/yyt2tu94. An expert on health law is skeptical that enough justices would agree to overturn the Affordable Care Act (ACA) in an upcoming case before the Supreme Court, even if Judge Amy Coney Barrett were to be confirmed for the court.

Neiding, Harper , “Barrett says she's ‘not hostile’ toward Affordable Care Act,” The Hill, Oct. 13, 2020, https://tinyurl.com/yxcdku7m. Judge Barrett, who previously criticized Chief Justice John Roberts's 2012 opinion upholding the Affordable Care Act, said in her confirmation hearing she was “not hostile” to the law.

Washburn, Lindy , “Affordable Care Act before Supreme Court puts health coverage at risk for 800,000 in NJ,” NorthJersey.com, Oct. 14, 2020, https://tinyurl.com/y6764xhw. In an effort to ensure that New Jersey residents retain health insurance coverage if the ACA is overturned, New Jersey opened its new online health insurance marketplace, which would replace the ACA's if needed.

COVID-19

Ramey, Elisse , “Whitmer asks for extension of health insurance sign-ups due to coronavirus,” ABC-12 News, Oct. 15, 2020, https://tinyurl.com/y4mhnbm5. Michigan Gov. Gretchen Whitmer has called for the open enrollment period for the online health insurance marketplace to be extended due to the large numbers of people who lost jobs during the pandemic.

Schnecker, Lisa , “Getting used to seeing your doctor virtually? Telehealth coverage might not last,” The Philadelphia Inquirer, Oct. 15, 2020, https://tinyurl.com/y4atk5nd. It is unclear how much longer health insurers will cover telehealth appointments, unless state and federal lawmakers require them to do so.

Vasan, Paula , “How lack of health insurance is impacting the Latinx community during COVID-19,” WHAS11, Oct. 15, 2020, https://tinyurl.com/yx99cqzu. Latinos in Kentucky are disproportionately more likely to contract COVID-19 and less likely to have health insurance than other demographic groups.

Employer-Based Insurance

Rothberg, Ethan , “As costs soar for employer-based health insurance, here's how to fight back,” Yahoo Finance, Oct. 14, 2020, https://tinyurl.com/y6n4xays. The average annual premium for employer-based family coverage in the first half of 2020 was up 4 percent from a year earlier.

Thompson, Ashley , “Kemp announces federal approval of health care reform plan,” CBS 46, Oct. 15, 2020, https://tinyurl.com/y6asjuvc. Georgia Gov. Brian Kemp received federal approval to implement a plan for the state to assist with some employees' employer-sponsored health insurance premiums and copays, in lieu of expanding Medicaid.

Uhler, Andy , “How losing a job can make the pandemic worse,” Marketplace, Oct. 15, 2020, https://tinyurl.com/y2a896ne. Around 85 percent of Americans who recently lost their employer-based insurance are eligible for coverage through an ACA marketplace or Medicaid.

Medicare for All

Dudzic, Mark , “Democrats Should Be Ashamed of the Rejection of Medicare for All in the DNC Platform,” Jacobin, Aug. 20, 2020, https://tinyurl.com/yxcw8g7t. Democratic socialists criticized the Democratic National Convention's decision not to endorse Medicare for All in its platform.

Laszewski, Robert , “Kamala Harris Has Had Some Difficulty With The Health Care Issue,” Forbes, Aug. 15, 2020, https://tinyurl.com/yynenh3n. Democratic vice presidential nominee Kamala Harris has moved away from supporting Sen. Bernie Sanders' proposal for Medicare for All, first by introducing during the primaries her own plan, which would maintain a form of private health insurance, and now by agreeing with her running mate's less transformative public option proposal.

Murad, Yusra , “As Coronavirus Surges, ‘Medicare for All’ Support Hits 9-Month High,” Morning Consult, April 1, 2020, https://tinyurl.com/qqseozm. As the pandemic took hold in the United States this spring, support for Medicare for All rose.

Contacts America's Health Insurance Plans 601 Pennsylvania Ave., N.W., South Building, Suite 500, Washington, DC 20004 202-778-3200 ahip.org Trade association for health insurance companies.

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http://ahip.org

Commonwealth Fund 1 E. 75th St., New York, NY 10021 212-606-3800 cmwf.org A private foundation that funds independent research on health care, including cost, access and quality in the United States and abroad.

Congressional Research Service 101 Independence Ave., S.E., Washington, DC 20540 202-707-5000 crsreports.congress.gov Congress' research arm that provides nonpartisan briefing papers on health care and other issues.

Kaiser Family Foundation 185 Berry St., Suite 2000, San Francisco, CA 94107 650-854-9400 kff.org Nonpartisan organization that provides in-depth studies of federal and state health care issues.

Medicare Payment Advisory Commission 425 I St., N.W., Suite 701, Washington, DC 20001 202-220-3700 medpac.gov Federal advisory group that conducts detailed research on Medicare, including insurer-run Medicare Advantage plans.

Robert Wood Johnson Foundation 50 College Road East, Princeton, NJ 08540-6614 609-627-6000 rwjf.org Philanthropy focused solely on health that funds studies of insurance issues.

Urban Institute 500 L'Enfant Plaza, S.W., Washington, DC 20024 202-833-7200 urban.org An organization of social scientists, economists, communicators, mathematicians, demographers and data scientists that conducts research on social issues, including health, housing, justice and education.

Footnotes [1] Andrew Schwab, “A System Under Stress, Exacerbated: The Employer-Sponsored Health Insurance System at Crossroads,” United States of Care, Sept. 9, 2020, https://tinyurl.com/y6m7r28w.

[2] Kaiser Family Foundation, “Health Insurance Coverage of the Total Population,” https://tinyurl.com/y3dafsbo.

[3] Bowen Garrett and Anuj Gangopadhyaya, “How the COVID-19 Recession Could Affect Health Insurance Coverage,” Urban Institute, May 4, 2020, https://tinyurl.com/y8p73b37.

[4] Leana S. Wen and Nakisa B. Sadeghi, “Addressing Racial Health Disparities in The COVID-19 Pandemic: Immediate And Long-Term Policy Solutions,” Health Affairs, July 20, 2020, https://tinyurl.com/y3j487sb.

[5] “Protection from high medical costs,” U.S. Centers for Medicare and Medicaid Services, https://tinyurl.com/zkwumnm.

[6] Christopher S. Girod et al., “2020 Milliman Medical Index,” Milliman, May 21, 2020, https://tinyurl.com/yy45b2po; Anna Wilde Mathews, “Cost of Employer-Provided Health Coverage Passes $20,000 a Year,” The Wall Street Journal, Sept. 25, 2019, https://tinyurl.com/yypvtk8j.

[7] Dan Witters, “In U.S., 14% With Likely COVID-19 to Avoid Care Due to Cost,” Gallup, April 28, 2020, https://tinyurl.com/y5g4gwt2.

[8] Karen Davis et al., “Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally,” Commonwealth Fund, June 16, 2014, https://tinyurl.com/ybdokmls.

[9] “An Overview of Medicare,” Kaiser Family Foundation, Feb. 13, 2019, https://tinyurl.com/y2ep48pq; Robin Rudowitz, Rachel Garfield and Elizabeth Hinton, “10 Things to Know About Medicaid: Setting the Facts Straight,” Kaiser Family Foundation, March 6, 2019, https://tinyurl.com/y299ouak; and Edward R. Berchick, Jessica C. Barnett and Rachel D. Upton, “Health Insurance Coverage in the United States: 2018,” U.S. Census Bureau, November 2019, https://tinyurl.com/y462mzls.

[10] Berchick, Barnett and Upton, ibid.

[11] “2019 Employer Health Benefits Survey,” Kaiser Family Foundation, Sept. 25, 2019, https://tinyurl.com/y22bopfp.

[12] Rachel Garfield, Kendal Orgera and Anthony Damico, “The Uninsured and the ACA: A Primer — Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act,” Kaiser Family Foundation, Jan. 25, 2019, https://tinyurl.com/yxak8r8s.

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[13] Sara Rosenbaum and Timothy M. Westmoreland, “The Supreme Court's Surprising Decision On The Medicaid Expansion: How Will The Federal Government And States Proceed?” Health Affairs, August 2012, https://tinyurl.com/y3f9exn5.

[14] Anuj Gangopadhyaya, Michael Karpman, and Joshua Aarons, “As the COVID-19 Recession Extended into the Summer of 2020, More Than 3 Million Adults Lost Employer-Sponsored Health Insurance Coverage and 2 Million Became Uninsured,” Urban Institute, Sept. 18. 2020, https://tinyurl.com/y5boeoce.

[15] Ibid.

[16] Josh Bivens and Ben Zipperer, “Health insurance and the COVID-19 shock: What we know so far about health insurance losses and what it means for policy,” Economic Policy Institute, Aug. 26, 2020, https://tinyurl.com/y4mdfo4m.

[17] Chris Sloan et al., “COVID-19 Projected to Worsen Racial Disparities in Health Coverage,” Avalere Health, Sept. 16, 2020, https://tinyurl.com/y69s8umy.

[18] Jessica Banthin and John Holahan, “Making Sense of Competing Estimates: The COVID-19 Recession's Effect on Health-Insurance Coverage,” Urban Institute, Aug. 27, 2020, https://tinyurl.com/y23lljnf.

[19] Ibid.

[20] Reed Abelson, “Some Workers Face Looming Cutoffs In Health Insurance,” The New York Times, Sept. 28, 2020, https://tinyurl.com/y3wz7l7g.

[21] Leemore S. Dafny et al., “How Has Covid-19 Affected Health Insurance Offered by Small Businesses in the U.S.? Early Evidence from a Survey,” The New England Journal of Medicine, Aug. 14, 2020, https://tinyurl.com/y65xja2u.

[22] Matt Seidholz, “3 Months on COBRA health insurance cost my family over $8,000, but it was our lifeline when my wife needed care,” Business Insider, March 31, 2020, https://tinyurl.com/y6p3nusl.

[23] Garrett and Gangopadhyaha, op. cit.

[24] Sarah Kliff and Margot Sanger-Katz, “Without Ginsburg, Supreme Court Could Rule Three Ways on Obamacare,” The New York Times, Sept. 21, 2020, https://tinyurl.com/y5k5h9yf.

[25] Andrew Schwab, “A System Under Stress, Exacerbated: The Employer-Sponsored Health Insurance System at a Crossroads,” United States of Care, Sept. 9, 2020, https://tinyurl.com/y6m7r28w.

[26] Reed Abelson, “Major U.S. Health Insurers Report Big Profits, Benefiting From the Pandemic,” The New York Times, Aug. 5, 2020, https://tinyurl.com/y3c2kfhb.

[27] Kim Parker, Rachel Minkin and Jesse Bennett, “Economic Fallout From COVID-19 Continues to Hit Lower-Income Americans the Hardest,” Pew Research Center, Sept. 24, 2020, https://tinyurl.com/y6gux52d.

[28] “Tax Expenditures,” U.S. Treasury Department, https://tinyurl.com/y6dctfwt.

[29] Laura J. Hay, “Do insurers have COVID-19 covered?” KPMG, 2020, https://tinyurl.com/y4ul9jsy.

[30] Abelson, “Major U.S. Health Insurers Report Big Profits, Benefitting From the Pandemic,” op. cit.

[31] Reed Abelson, “Coronavirus May Add Billions to U.S. Health Care Bill,” The New York Times, March 28, 2020, https://tinyurl.com/yxdg9gg2.

[32] Ge Bai and Gerard F. Anderson, “COVID-19 And The Financial Viability of US Rural Hospitals,” Health Affairs, July 1, 2020, https://tinyurl.com/y45ueurq.

[33] Christopher Jackson, “Impact of COVID-19 on the Health Insurance Industry,” Marcum Accountants & Advisors, April 21, 2020, https://tinyurl.com/y4serfvh.

[34] Abelson, “Coronavirus May Add Billions to U.S. Health Care Bill,” op. cit.

[35] “Covered California Releases the First National Projection of the Coronavirus (COVID-19) Pandemic's Cost to Millions of Americans With Employer or Individual Insurance Coverage,” Covered California, March 24, 2020, https://tinyurl.com/utynpb7.

[36] Bertha Coombs, “Coronavirus outbreak is already upending health insurance premiums and copays for next year,” CNBC, July 15, 2020, https://tinyurl.com/yc5r74st.

[37] Lev Facher, “9 ways Covid-19 may forever upend the U.S. healthcare industry,” Stat, May 19, 2020, https://tinyurl.com/y5ttxecf.

[38] Yusra Murad, “As Coronavirus Surges, ‘Medicare for All’ Support Hits 9-Month High,” Morning Consult, April 1, 2020, https://tinyurl.com/qqseozm.

[39] Sheryl Gay Stolberg, “G.O.P. Faces Risk From Push to Repeal Health Law During Pandemic,” The New York Times, June 22, 2020, https://tinyurl.com/y9rlrrpo.

[40] Matthew Yglesias, “Joe Biden's health care plan, explained,” Vox, July 16, 2019, https://tinyurl.com/y6lhxp8r.

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[41] “Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage,” Kaiser Family Foundation, Oct. 16, 2020, https://tinyurl.com/yyzatu9o.

[42] Alice Miranda Ollstein, “‘This is health care moonshot time’: Pandemic pulls Biden, Dems further left,” Politico, July 28, 2020, https://tinyurl.com/y5y7khm8.

[43] Reed Abelson, “Major U.S. Health Insurers Report Big Profits, Benefiting From the Pandemic,” op. cit.

[44] Libby Watson, “The Case for Single-Payer in a Pandemic,” The New Republic, April 14, 2020, https://tinyurl.com/y3f69c4n.

[45] Aaron E. Carroll, “The Real Reason the U.S. Has Employer-Sponsored Health Insurance,” The New York Times, Sept. 5, 2017, https://tinyurl.com/y8keens4.

[46] Christine S. Spencer, Darrell J. Gaskin and Eric T. Roberts, “The Quality Of Care Delivered To Patients Within The Same Hospital Varies By Insurance Types,” Health Affairs, October 2013, https://tinyurl.com/y2uwkwc8.

[47] Adewole S. Adamson et al., “Association of Delays in Surgery for Melanoma With Insurance Type,” JAMA Dermatology, November 2017, https://tinyurl.com/y3upue8q.

[48] Jean-Pierre Unger and Pierre De Paepe, “Commercial Health Care Financing: The Cause of U.S., Dutch, and Swiss Health Systems Inefficiency?” International Journal of Health Services, May 8, 2019, https://tinyurl.com/y5pstrac.

[49] Ibid.

[50] Ibid.

[51] Stuart Heiser, “New Findings Confirm Predictions on Physician Shortage,” Association of American Medical Colleges, April 2019, https://tinyurl.com/qv2d72d.

[52] “Uninsured Rates for the Nonelderly by Race/Ethnicity,” Kaiser Family Foundation, https://tinyurl.com/ya28pmdd.

[53] “Health Equity Considerations and Racial and Ethnic Minority Groups,” Centers for Disease Control and Prevention, July 24, 2020, https://tinyurl.com/y3otmerp.

[54] Heeju Sohn, “Racial and Ethnic Disparities in Health Insurance Coverage: Dynamics of Gaining and Losing Coverage over the Life-Course,” Population Research and Policy Review, Oct. 15, 2016, https://tinyurl.com/y6y3hgo6.

[55] Christen Linke Young, “There are clear, race-based inequalities in health insurance and health outcomes,” Brookings Institution, Feb. 19, 2020, https://tinyurl.com/y4rssh5r.

[56] Sara Rosenbaum, Rebecca Morris and Maria Velasquez, “States Can Test for COVID-19 Under the Uninsured Medicaid Option, but Why Are Many Opting Out?” Commonwealth Fund, Aug. 13, 2020, https://tinyurl.com/y2o3ezdu.

[57] Elisabeth Rosenthal, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (2017), p. 14.

[58] Alex Blumberg and Adam Davidson, “Accidents of History Created U.S. Health System,” NPR, Oct. 22, 2009, https://tinyurl.com/yyurcngr; Barbra Mann Wall, “History of Hospitals,” Penn Nursing, https://tinyurl.com/y53oseeg.

[59] John Steele Gordon, “A Short History of American Medical Insurance,” Imprimis, September 2018, https://tinyurl.com/yaqjkfyx.

[60] “Since insurance's humble start in Dallas, hospital inflation has always posed challenge,” Dallas Morning News, March 6, 2015, https://tinyurl.com/yyajuxjm.

[61] Blumberg and Davidson, op. cit.

[62] Carroll, op. cit.

[63] Rosenthal, op. cit., p. 16.

[64] Carroll, op. cit.; Gordon, op. cit.

[65] Rosenthal, op. cit.

[66] Melissa A. Thomasson, “From Sickness to Health: The Twentieth-Century Development of U.S. Health Insurance,” Explorations in American History, July 2002, https://tinyurl.com/y2l3ohw5.

[67] “How it all started,” Kaiser Permanente, July 21, 2011, https://tinyurl.com/y4ooryto.

[68] Laura A. Scofea, “The Development and Growth of Employer-Provided Health Insurance,” Monthly Labor Review, March 1994, https://tinyurl.com/yxv8gq2z.

[69] Blumberg and Davidson, op. cit.

[70] Brigitte C. Madrian, “Employment-Based Health Insurance and Job Mobility: Is There Evidence of Job-Lock?” The Quarterly Journal of Economics, Oxford University Press, Feb. 1, 1994, pp. 27-54, https://tinyurl.com/y5kdwo55.

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[71] Howard Markel, “69 years ago, a president pitches his idea for national health care,” PBS Newshour, Nov. 19, 2014, https://tinyurl.com/y42ekj64.

[72] Martin Gorksy, “The British National Health Service 1948-2008: A Review of the Historiography,” Social History of Medicine, Oct. 19, 2008, pp. 437-460, https://tinyurl.com/y2lzdeyw; “Milestones: universal policies,” Canadian Public Health Association, https://tinyurl.com/y5vsuod2.

[73] “Jan. 30, 1974: State of the Union Address,” The Miller Center, Jan. 30, 1974, https://tinyurl.com/y23rwbvr; N.R. Kleinfield, “The King of the H.M.O. Mountain,” The New York Times, July 31, 1983, https://tinyurl.com/yyjf5cpo; Lynn R. Gruber, Maureen Shadle and Cynthia L. Polich, “From Movement To Industry: The Growth Of HMOs,” Health Affairs, Jan. 1, 1988, https://tinyurl.com/y5fd55ce; and Adam Clymer, Robert Pear and Robin Toner, “The Health Care Debate: What Went Wrong? How the Health Care Campaign Collapsed,” The New York Times, Aug. 29, 1994, https://tinyurl.com/y6fy35sb.

[74] “State Children's Health Insurance Program,” Benefits.gov, https://tinyurl.com/y46ca6zd; “July 2020 Medicaid & CHIP Enrollment Data Highlights,” op. cit.

[75] Rosenthal, op. cit., p. 17.

[76] Ibid.

[77] The Washington Post staff, Landmark: The Inside Story of America's New Health-Care Law and What It Means for Us All (2010), pp. 73-83; Jennifer Tolbert et al., “Key Facts about the Uninsured Population,” Kaiser Family Foundation, Dec. 13, 2019, https://tinyurl.com/uyjvvo6.

[78] Rachel Garfield, Kendal Orgera and Anthony Damico, “The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid,” Kaiser Family Foundation, Jan. 14, 2020, https://tinyurl.com/y3yccjdt.

[79] Thomas Kaplan and Robert Pear, “House Passes Measure to Repeal and Replace the Affordable Care Act,” The New York Times, May 4, 2017, https://tinyurl.com/m3m9wta.

[80] Sheryl Gay Stolberg, “Trump Administration Asks Supreme Court to Strike Down Affordable Care Act,” The New York Times, June 26, 2020, https://tinyurl.com/y9ct24lj.

[81] Kaitlan Collins et al., “Barr urges Trump administration to back off call to fully strike down Obamacare,” CNN, May 5, 2020, https://tinyurl.com/ycg57mhh.

[82] Michelle Andrews, “Rule Change Gives Laid-Off Workers More Time To Sign Up for COBRA Insurance,” NPR, July 20, 2020, https://tinyurl.com/y2tptxm5.

[83] Susannah Luthi, “The unlikely alliance trying to rescue workplace health insurance,” Politico, April 28, 2020, https://tinyurl.com/y5vmh9d7.

[84] Susannah Luthi, “White House eyeing stimulus funds to cover uninsured,” Politico, April 2, 2020, https://tinyurl.com/tecvs57.

[85] Coombs, op. cit.

[86] Rachel Roubein, “Missouri voters latest to approve Medicaid expansion,” Politico, Aug. 5, 2020, https://tinyurl.com/y483256k.

[87] Sarah Kliff, “How Progressives Flipped the Script on Medicaid Expansion,” The New York Times, Aug. 4, 2020, https://tinyurl.com/y2xsj9pt.

[88] Dan Goldberg, “Pandemic upends state plans to expand health insurance,” Politico, May 28. 2020, https://tinyurl.com/y75eljs2.

[89] Saja Hindi, “Colorado lawmakers shelve contentious hybrid public option bill amid the pandemic,” The Denver Post, May 4, 2020, https://tinyurl.com/y24dkexj.

[90] Goldberg, op. cit.

[91] Dylan Scott, “If Trump wins, 20 million people could lose health insurance. If Biden wins, 25 million could gain it,” Vox, Sept. 30, 2020, https://tinyurl.com/y5kmgcef.

[92] Cynthia Cox et al., “Affordability in the ACA Marketplace Under a Proposal Like Joe Biden's Health Plan,” Kaiser Family Foundation, Sept. 28, 2020, https://tinyurl.com/y6onb58r.

[93] Scott, op. cit.

[94] Rebecca Pifer, “5 key pillars of Biden's healthcare plan,” Healthcare Dive, April 28, 2020, https://tinyurl.com/yxtzt9ns.

[95] Sarah Kliff and Dylan Scott, “Trump's quiet campaign to bring back preexisting conditions,” Vox, Feb. 22, 2018, https://tinyurl.com/y445dlqv.

[96] Sarah Kliff and Margot Sanger-Katz, “Without Ginsburg, Supreme Court Could Rule Three Ways on Obamacare,” The New York Times, Sept. 21, 2020, https://tinyurl.com/y5k5h9yf.

[97] Abby Goodnough, “Obamacare Returns as Galvanizing Issue After Ginsburg Death and Barrett Nomination,” The New York Times, Sept. 27, 2020, https://tinyurl.com/y26ccbl8.

[98] Ibid.

[99] Facher, op. cit.

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[100] Rebecca Robbins and Erin Brodwin, “As insurers move this week to stop waiving telehealth copays, patients may have to pay more for virtual care,” Stat, Sept. 29. 2020, https://tinyurl.com/y3pgq54p.

[101] Reed Abelson, “Is Telemedicine Here to Stay?” The New York Times, Aug. 3, 2020, https://tinyurl.com/yxvmzabk.

[102] Ibid.

About the Author Holly Rosenkrantz is a Washington-based freelance journalist who writes about politics, business and health care. She is a former White House correspondent and Wall Street reporter and has written for The New York Times, The Washington Post, CBS News, Bloomberg News and Reuters.

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#top

Introduction
Overview

Can the employer-based health insurance system survive the COVID-19 pandemic?
Has the COVID-19 pandemic increased support for a single-payer system such as Medicare for All?
Does employer-based insurance produce better health outcomes?

Background

Evolution of Employer-Based Insurance
Government Plans
The Rise of Insurance Companies

Current Situation

Threatened Coverage
2020 Politics
Supreme Court Challenge

Outlook

Telemedicine Growth

Pro/Con

Chronology
Short Features
Bibliography

Books
Articles
Reports and Studies

The Next Step

Affordable Care Act
COVID-19
Employer-Based Insurance
Medicare for All

Contacts
Footnotes
About the Author