Chapters authored
Primary Care in the USA: The Long Struggle to Build its Foundational Role
Family practice was recognized as the 20th specialty in American medicine in 1969. With the hope that primary care would become the foundation of an improved health care system, vigorous efforts were launched in medical education, research and practice to achieve that goal. This chapter traces the history of that effort, together with negative system changes that have obstructed that goal. Although primary care physicians have been shown to improve access to care, contain costs, decrease inequities, and improve patient outcomes, they are still too few in number to meet national needs for primary care. The COVID-19 pandemic revealed the extent of inadequacy and vulnerability of the system. The U. S. still lacks a system of universal access as has been in place for many years in most other advanced countries around the world. Corporate stakeholders in a largely privatized financing and delivery system continue to challenge the future of primary care. Lessons from the failure of reform initiatives over the last 50 years are discussed, as are current reform alternatives, only one of which would at last bring universal access to health care in this country.
Part of the book: Primary Health Care
Health Insurance in the United States: Failure of Private and Multi-Payer Financing
Since the 1960s, the United States has subscribed to a business model of health care, largely for-profit with most private insurers on a mission to maximize their own revenues. Most insurers use cost sharing through deductibles and copayments based on the principle that enrollees will overuse health care services unless they have enough “skin in the game.” As health care has been corporatized within a medical-industrial complex, even public insurers such as Medicare and Medicaid have been privatized with the same mission. Employer-sponsored health insurance has been the core of insurance in the U.S. since World War II, but has become unaffordable for employers and employees alike. This article brings historical perspective to how health insurance has been transformed from its not-for-profit origins in the 1930s, how it has become unaffordable in recent decades as it costs more and covers less, and how our multi-payer financing system has failed the public interest. Reform alternatives are discussed, but a system of universal coverage through a public, single-payer national plan is still beyond reach politically.
Part of the book: Health Insurance