Controversial Topic: Health Insurance

Health Insurance refers to financial coverage for healthcare expenses. Health coverage is among the most intensely debated subjects in American life, both because of the generally high cost of healthcare expenses, and because access to coverage varies significantly based on employment and socioeconomic status. Some Americans believe the government should take greater responsibility for the millions who are uninsured or underinsured, with many arguing that the United States should provide universal health coverage for all Americans. By contrast, others believe that paying for health coverage should be the individual responsibility of every American, and argue that universal healthcare coverage is a socialist policy.

Controversial Topic: Health Insurance

Today, health insurance is largely a privatized industry in which various health insurance providers compete for clients. Most insured Americans have health insurance coverage through employers, and in most cases, pay some portion of this expense through paycheck deductions. As of 2010, 55.1% of Americans were covered through employer-sponsored plans. Another 34.4%—typically the elderly, disabled, and those living below the poverty line—are covered through the publicly-funded Medicare and Medicaid plans.

To learn more about these coverage options, check out our look at the Social Security Controversy.

An additional 5% of Americans are covered through plans selected on the Affordable Care Act (ACA) marketplace. However, at the time of writing, there are roughly 30 million Americans without health insurance. And the massive employment crisis created by the COVID-19 pandemic has seen a further drop in the number of Americans with coverage through their employers. Individuals living without health insurance face far greater health risks and a higher mortality rate because they are more likely to avoid care for existing health conditions, to take preventative health screening measures, or to have access to adequate treatment. The ever-rising cost of medical expenses further magnifies the challenges faced by those without health insurance.

These conditions frame the debate over health insurance between two distinct and competing viewpoints:

  • Healthcare is a right that should be afforded to all citizens through significant reform of the existing healthcare system with a move toward universal single-payer healthcare coverage, in which taxpayers’ money is used to fund a single, publicly administered health insurance programs that is affordable, or free, to all Americans who need it; or
  • Public funding for healthcare unfairly passes the tax burden along to individuals who already pay into their own healthcare expenses, would widely diminish efficiency and quality of care and would drive up deficit spend. Some argue that healthcare reform should instead be sought through expansion of existing public programs and greater incentivization of employer-sponsored health coverage.

While healthcare reform is a top political issue for most Americans, and while observers on both sides believe that reform is necessary, there are competing views on how to pursue this reform. The healthcare reform issue often splits on political party lines, with those who identify as liberal, progressive, or Democratic more likely to support expanded public funding for health insurance. Some in these demographics support universal health coverage, arguing that the United States is actually the only developed, democratic nation in the world which does not ensure health coverage for all of its citizens. Some advocates have called for a “single-payer” health insurance program, in which the competitive marketplace is replaced by a single, quasi-public coverage provider.

Those who identify as conservative, libertarian or Republican are more likely to argue that health coverage is a personal choice, and that Americans who have earned coverage through employment or by financing it themselves have the right to abstain from funding care for others. Also aligned with this view are those who argue that a competitive health coverage market follows the general spirit of capitalism, a position that is shared by health insurance companies and their lobby groups. They argue that an absence of market competition would reduce quality and availability, while also raising national debt and deficits.

The goal of this discussion is to examine the various perspectives shaping the public discussion over health insurance, and to provide you with a look at some of the figures past and present who have influenced this discussion. The figures selected may not always be household names, but are instead selected to provide a nuanced look at the public discourse on this subject, and in some cases, even to provide you with a list of individuals to contact as part of your research.

A Brief History of The Issue

Early Forms of Insurance

In the U.S., the Industrial Age saw the emergence of a few early modes of insurance coverage, including:

  • The first accident insurance in 1850, provided by the Franklin Health Assurance Company of Massachusetts for those injured in railroad or steamboat accidents;
  • The first sickness coverage, dated around 1890; and
  • The first employer-sponsored disability policy, in 1911.

In most cases, the coverage provided from these insurance policies was for disability from work, rather than for the coverage of medical expenses.

Fee for Service Medicine

In the early 20th Century, all medical service costs were paid out of pocket on a fee-for-service basis. However, the 1920s saw the initiation of pre-paid services in some hospitals, where an individual would pay a modest monthly fee to a specific local hospital for some measure of coverage in the event of an upcoming hospital visit. As such services became more widespread, Blue Cross organizations emerged to broker such arrangements. These Blue Cross organizations began providing predetermined levels of medical coverage for individuals who paid into such plans. The first of such models, an employer-sponsored plan for teachers in Dallas, Texas, went into effect in 1929. As this model became more widespread, the early accident and disability companies gradually evolved into medical coverage agencies.

Employer-Sponsored Coverage

During World War II, the United States experienced both a labor shortage and an increased demand for goods. However, federally-imposed wage and price controls prevented companies from luring workers by dramatically scaling up pay. By contrast, benefits such as health coverage were not counted against the wage cap. As companies used the promise of health coverage to attract workers during the war, employer-sponsored health insurance proliferated widely throughout the U.S. The Revenue Act of 1954 permanently instituted a tax deduction for companies providing their employees with access to health coverage.

Public Health Coverage

In 1945, President Truman outlined his plan for a national system that would be optional, but accessible to every American for a monthly fee. This would cover all medical expenses as well as disability coverage for lost wages due to illness or injury. In spite of the plan’s popularity with the general public, it was derided as socialism by an axis of powerful professional groups including the American Medical Association (AMA), American Hospital Association (AHA), and the Chamber of Commerce. In many ways, this would be the starting point for a public debate over health coverage in the U.S. that has persisted for 75 years.

Truman’s plan was never adopted, and it would be another 20 years before a true public option would become available. In 1965, President Lyndon Johnson signed the Social Security Amendments of 1965, creating Medicare and Medicaid programs. This would provide public coverage for the elderly and poor for the first time. Coverage would later be expanded to include the disabled and those with certain terminal conditions.

To learn more about Medicare and Medicaid, check out our look at the Social Security Controversy.

While Medicare and Medicaid widely expanded access to public coverage, and employer-sponsored health coverage extended to many full-time workers, millions of Americans continued to lack access to coverage, either public or private. The 1970s saw meaningful debate on the subject, but little actual movement. Democratic Senator Ted Kennedy became one of the first prominent legislators to advocate for a “universal single-payer system,” but butted heads with President Nixon, who instead supported expansion of existing public coverage and incentives to employers for making coverage more widely available to American workers.

No compromise was reached prior to Nixon’s 1974 resignation, which effectively scuttled the conversation for another two decades. During that time, Democrats and Republicans largely staked out two competing positions on the subject, with the former pushing increasingly for expanded, or universal, health coverage and the latter arguing that a single-payer system was tantamount to socialism.

Affordable Care Act

Even as fierce debate persisted, healthcare costs spiraled out of control, and the number of uninsured Americans numbered in the tens of millions, health insurance reform was elusive until President Obama’s 2008 election. Healthcare reform was a top priority for the incoming Obama Administration, which passed the Affordable Care Act through a divided Congress in 2010. The new plan, sometimes also referred to as Obamacare, mandated that employers provide access to coverage options, and created a marketplace where individuals could access private coverage. The Act also restricted companies from denying coverage to those with “preexisting conditions.”

Though the Act generated intense partisan disagreement, more than 16 million previously uninsured Americans obtained coverage during its first five years. According to healthline.com, because of the ACA, “Insurance companies must now spend at least 80 percent of insurance premiums on medical care and improvements. The ACA also aims to prevent insurers from making unreasonable rate increases. Insurance coverage isn’t free by any means, but people now have a wider range of coverage options.”

There are many who still lack access to health insurance, healthcare costs continue to grow, and public healthcare spending is expected to account for nearly half of all public mandated spending by 2025. However, the Affordable Care Act effectively cut the number of Americans without health insurance in half. Efforts by Republican leaders in both the legislative and executive branches to repeal and replace the Affordable Care Act have so far been unsuccessful.

Top Ten Historical Influencers in the Health Insurance Controversy

Using our own backstage Ranking Analytics tools, we’ve compiled a list of the most influential figures around the health insurance debate in the U.S. between 1990 and 2020. Though our lists are typically vetted to exclude politicians and heads of state, the history outlined above reveals the direct impact that such figures have had on the public debate and policy development around health coverage. Absent this vetting, our ranking engine produced a list composed entirely of executive and legislative leaders who have impacted the direction of health coverage in the U.S. :

Top Ten Historical Influencers in the Health Insurance Controversy
Rank Person
1 Barack Obama
2 Donald Trump
3 George W. Bush
4 Hillary Clinton
5 Bill Clinton
6 Ronald Reagan
7 Mitt Romney
8 Bernie Sanders
9 John McCain
10 Ted Kennedy

Top Ten Most Influential Books About Health Insurance

Using our own backstage Ranking Analytics tools, we’ve compiled a list of the most influential books on the topic of health insurance in the U.S. between 1900 and 2020. This list is vetted to exclude popular fiction and otherwise irrelevant findings. The list is built from a combination of non-fiction texts on American healthcare, and reference sources concerning both medical policy and American legislative code:

Top Ten Historical Influential Books in the Civil Rights Debate
Rank Book Title
1 The Healing of America
2 United States Code
3 International Classification of Primary Care
4 The Undercover Economist
5 DSM-5
6 The World Is Flat
7 The Social Transformation of American Medicine
8 It Takes a Village
9 The Almanac of American Politics
10 Veto Players

The Current Controversy

The Affordable Care Act is now a decade old, and while it was effective at adding millions to the roll of insured Americans, healthcare costs and coverage remain top issues for legislators and Americans. Even with coverage, healthcare is a major expense for American families. According to the Brookings Institution, roughly 18% of the GDP is spent on healthcare today.

In spite of this, coverage remains elusive for many Americans. Roughly 27.5 million people, or 8.5% of the U.S. population still do not have health insurance. And in the economic fallout of the COVID-19 pandemic, this number has been on the rise. According to the Organization for Economic Co-operation and Development (OECD), the U.S. is the only nation among 37 affiliated nations “that does not have universal health care either in practice or by constitutional right.”

Accordingly, says top economist Paul Krugman, “cross-national survey conducted by the Commonwealth Fund found that America ranks near the bottom among advanced countries in terms of how hard it is to get medical attention on short notice” and that “America is the worst place in the advanced world if you need care after-hours or on a weekend.”

These conditions frame the present debate, which concerns the ability of Americans to both access and afford health coverage. While some members of the public, legislators, and policy experts support universal single-payer coverage for the millions of Americans who are uninsured or underinsured, other members of the public, legislators, and industry advocates believe that universal coverage is a form of socialism, and that acquiring and paying for health coverage should be the individual responsibility of every American.

A Quick Overview of Our Method

Our goal in presenting subjects that generate controversy is to provide you with a sense of some of the figures both past and present who have driven debate, produced widely-recognized works of research, literature or art, proliferated their ideas widely, or who are identified directly and publicly with some aspect of this debate. By identifying the researchers, activists, journalists, educators, academics, and other individuals connected with this debate—and by taking a closer look at their work and contributions—we can get a clear but nuanced look at the subject matter. Rather than framing the issue as one side versus the other, we bring various dimensions of the issue into discussion with one another. This will likely include dimensions of the debate that resonate with you, some dimensions that you find repulsive, and some dimensions that might simply reveal a perspective you hadn’t previously considered.

On the subject of health insurance, the debate requires us to consider those who have taken part in the early construction of the American “health insurance” infrastructure and those who have both advocated for and opposed the concepts of “universal health care” and “single-payer health care.” Also included in our research are key terms connected to both legislation and lobbying on the subject, such as the “Affordable Care Act,” “America’s Health Insurance Plans,” and the “Kaiser Foundation.” These key terms have produced a balance of those in favor of single-payer health coverage, those who have opposed universal care, and those who have attempted to stake out compromise between these two positions.

As with any topic that generates public debate and disagreement, this is a subject of great depth and breadth. We do not claim to probe either to the bottom of this depth or the borders of this breadth. Instead, we offer you one way to enter into this debate, to identify key players, and through their contributions to the debate, to develop a fuller understanding of the issue and perhaps even a better sense of where you stand.

For a closer look at how our InfluenceRankings work, check out our methodology.

Otherwise get started with a look at the key words we used to explore this subject:

Key Terms

Health Insurance

The key term in our discussion, “health insurance” refers to the array of options available to Americans for covering medical expenses, including employer-sponsored coverage, public options like Medicare and Medicaid, and private plans selected through the ACA marketplace. Our search results yielded a set of influencers on both sides of the debate–both those who have advocated for reform and those who have worked for or lobbied on behalf of the private health insurance industry.

Influencers:

  • Wendell Potter is an American advocate for health insurance payment reform, New York Times bestselling author, and former health insurance industry communications director. A critic of HMOs and the tactics used by health insurers, Potter is also a leading national advocate for major reforms of the health insurance industry, including Medicare for All and universal health care. Learn more…
  • Kenneth R. Melani is the former president and chief executive officer of Highmark, a health insurance company based in Pittsburgh and the largest health insurer in Pennsylvania. Before his abrupt departure from Highmark in 2012, he was one of the most powerful health insurance executives in the country. At his peak in 2012, Melani was in charge of a Highmark that was $14.6 billion company and had millions of policyholders, for which he was paid $4 million annually. Learn more…
  • Cathy A. Cowan, an economist, works for the National Health Statistics Group with the Office of the Actuary at the Centers for Medicare & Medicaid Services. For 25 years, she investigated the historical state-based and national estimations of capital spent on health care within the United States. Cowan specializes in health financing, private health insurance, out of pocket spending and the health costs of businesses, households, and the government. Similarly, she enjoys looking into comparing the health expenditure data with the household surveys along with international comparisons. Her education was expanded upon with a bachelor’s degree in business at Indiana University and a master’s degree in the University of South Carolina. In one particular study, Cathy A. Cowan, who was working as a business analyst at Health Care Financing Administration, concluded that the government and businesses each paid about a third of health care costs throughout the 1980s, along with an equal share from patients. During a news conference, the economist claimed that the national growth of health-care spending was slightly faster in 2006 than 2005 due to a 6.7 percent increase from a 6.5 percent growth. In fact, in 2006, expenditures reached $2.1 trillion, which is similar to $7000 a person in the United States. As a part of the World Health Organization, she was selected as the chair of the Global Health Expenditure Database’s Technical Advisory Group. Cowan’s fame was expanded when she was recognized as one of the world’s most influential scientific minds. Some of her well known works include “National Health Expenditures, “Business, Households and Government: Health Care Spending”, “Burden of Health Care Costs”, “Reconciling Medical Expenditure Estimates from the MEPS and NHE”, and “Out-of-pocket health care expenditures, by insurance status, 2007-10″. Learn more…

Health Coverage

While the “health coverage” term seems largely synonymous with health insurance, insofar as it refers to the variety of options for covering medical expenses, our search yielded influencers largely on the side of advocacy for expanded coverage access, including physicians, activists, and public health experts.

Influencers:

  • Joseph Walter Mountin MD was an American physician and career United States Public Health Service officer who was the founder of the U.S. Centers for Disease Control and Prevention in Atlanta, Georgia. Mountin eventually became an assistant surgeon general. He was involved in many advancements in medical and sanitary science during his lifetime. He was an early advocate for a national health care system and wrote frequently on the need to provide broader health care coverage. He was considered influential in the development of public health improvements. Learn more…
  • Carissa F. Etienne is a public health expert from Dominica. She serves as the Director of the Pan American Health Organization and Regional Director for the Americas of the World Health Organization. She is currently in her second five-year term as PAHO director having been re-elected by the Pan American Health Organization member states during the Pan American Sanitary Conference in September 2017. In January of 2018 she was named Regional Director for the Americas for the World Health Organization by its Executive Board based in Geneva. She is an advocate for universal health coverage. Learn more…
  • Andrew S. Cray was an American LGBTQ rights activist and political figure. Cray played a central role in securing new nationwide LGBTQ nondiscrimination protections as part of the Affordable Care Act, partnering with the White House and the Department of Health and Human Services to create the Out2Enroll initiative to connect LGBTQ people with health insurance coverage options, assisting with the passage of the HOPE Act to make organ donation and transplantation more accessible to people with HIV, and drafting new provisions addressing the needs of LGBTQ youth for the Runaway and Homeless Youth Act. Learn more…

Universal Health Care

The term “universal health care” refers to the idea that a national government should take responsibility to ensure that all citizens have access to medical coverage and care. This is the standard of coverage held by most developed, democratic nations. Advocates argue that the U.S. should adopt this same standard. Key influencers include such advocates from the medical and public health communities, as well as public leaders in other nations who have had a hand in implementing effective universal healthcare policies.

Influencers:

  • Linda Prine is an American family physician, author, professor, consultant, cyclist, non-profit founder, academy chair, health care director, fellowship director, and residency teacher best known nationally for her award-winning work as a reproductive rights and universal health care activist. Prine promotes making abortion care part of family health care. She is the medical director of the Reproductive Health Access Project, of which she is a co-founder. Learn more…
  • Matthew Huxley was an epidemiologist and anthropologist, as well as an educator and author. His work ranged from promoting universal health care to establishing standards of care for nursing home patients and the mentally ill to investigating the question of what is a socially sanctionable drug. Learn more…
  • Richard “Dick” Bailey Scotton AO was an Australian health economist, best known as one of the original key policy advisers who designed the Australian Medibank program—Australia’s first and current system of publicly funded universal health care, now known as Medicare. Learn more…

Single-Payer Health Care

Like universal coverage, “single-payer health care” refers to a system in which all citizens would have access to health coverage and care. This approach, which is advocated for by a number of public leaders with progressive ideologies, calls for a single, quasi-public agency to administer distribution of coverage to all Americans. Key influencers include such advocates from the medical and public health communities.

Influencers:

  • David A. Ansell is a Chicago-based physician, social epidemiologist and author. His efforts at both the national and local levels have advanced concerns about health inequities and the structure of the US health care system. His years as a provider to the medically underserved have made him a vocal supporter of single-payer health care. He spent seventeen years at Cook County Hospital currently known as John H. Stroger Hospital of Cook County upon which the medical T.V. drama ER was based. Ansell was inspired by his time at Cook County Hospital to write a memoir and social history entitled, County: Life, Death, and Politics in Chicago’s Public Hospital. County was hailed as a “landmark book” by Julia Keller of the Chicago Tribune, aiming “to inform and to inspire” readers about the disparities in health care. In the book, Ansell argues that only a single-payer solution that provides access to all US residents regardless of circumstances can provide relief for those closed out of the health care system. Learn more…
  • Mark Dudzic is the National Organizer and Chairman of the United States Labor Party as well as a labor activist. For 18 years, prior to becoming Labor Party Chairman, Dudzic was president of Local 8-149 OCAW . He is also the national coordinator for the Labor Campaign for Single Payer, which advocates for single-payer health care. Learn more…
  • Arnold Seymour Relman — known as Bud Relman to intimates — was an American internist and professor of medicine and social medicine. He was editor of The New England Journal of Medicine from 1977 to 1991, where he instituted two important policies: one asking the popular press not to report on articles before publication and another requiring authors to disclose conflicts of interest. He wrote extensively on medical publishing and reform of the U.S. health care system, advocating non-profit delivery of single-payer health care. Relman ended his career as professor emeritus at Harvard Medical School in Boston, Massachusetts. Learn more…

Affordable Care Act

Passed in 2010 by the Obama Administration, the Affordable Care Act (ACA), sometimes also referred to as Obamacare, was the first major reform to the health insurance system in decades. By eliminating preexisting conditions, mandating that employers provide health coverage options, and creating a state-by-state online marketplace for selecting from affordable plans, the ACA cut the number of uninsured Americans in half. Though the policy continues to generate partisan debate, it is the current law of the land. Influencers include both those who helped to develop this policy and those who have publicly opposed it.

Influencers:

  • Jonathan Turley is professor of law at the George Washington University’s Law School. He graduated from the University of Chicago with a B.A. before going on to earn a J.D. from Northwestern University. Turley is an expert in public interest law and an advocate for the constitutional rights and civil liberties of American citizens. Turley is a frequent publisher and commentator on legal issues. Law Dragon has ranked him among the nation’s top lawyers, top military lawyers, and most famous law professors, a testament to his ongoing impact on the legal profession. He has been a vocal and harsh critic of President Barack Obama’s Affordable Care Act, even representing John Boehner’s Republican Party in a suit asserting the unconstitutionality of the Affordable Care Acts’ individual mandate. Learn more…
  • Brad Woodhouse is an American Democratic Party activist who currently serves as the president of Protect Our Care, a group seeking to protect the Affordable Care Act. He also serves as co-chair of the Health Care Voter campaign. He is the former president of the now-defunct liberal/progressive advocacy group Americans United for Change. He has also served as the president of Democratic super PACs American Bridge 21st Century and Correct the Record. He is the former communications director of the United States Democratic National Committee. Learn more…
  • Elliott S. Fisher is a health policy researcher and advocate for improving health system performance in the United States. He helped develop the concept of accountable care organizations and championed their adoption by Medicare. The development of the Affordable Care Act was influenced by his research on disparities in healthcare spending and utilization across the United States. He has strongly supported a rapid transition from fee-for-service to pay-for-performance models in the U.S. healthcare industry. He is a tenured faculty member at Dartmouth College, where he teaches in the Masters in Public Health program. In August 2018, he was placed on paid administrative leave following a complaint about misconduct in the workplace and banned from the college campus. In April 2019, he was removed as director of The Dartmouth Institute for Health Policy and Clinical Practice after an investigation into misconduct in the workplace. He continues to be physically banned from parts of the college campus for a period of two years as a condition of his return to the faculty. Learn more…

America’s Health Insurance Plans (AHIP)

A lobby group with significant political influence, AHIP is a representation of those industry groups which have opposed reforms such as the Affordable Care Act, and which continue to build arguments against the adoption of a universal, single-payer healthcare system. Influencers in this area are typically those who have served in leadership roles within private healthcare and insurance industries.

Influencers:

  • Karen Ignagni is the President and Chief Executive Officer of EmblemHealth as of 9/1/2015, until which time she was the President and Chief Executive Officer of America’s Health Insurance Plans, formerly HIAA. She is often mentioned as one of the most effective lobbyists and the most powerful people in healthcare. She is involved in health care reform in the United States, working to benefit health insurance companies. Learn more…

Kaiser Foundation

The Kaiser Foundation is a left-leaning think tank that generally advocates for reform of healthcare and the health insurance industry. Its interest in realistic public health reform has inclined the Kaiser Foundation to frequently stake out a position of compromise between private and public options. Influencers include experts in public health, public policy, and hospital administration.

Influencers:

  • Robert J. Blendon is the Richard L. Menschel Professor of Public Health and Professor of Health Policy and Political Analysis, Emeritus and Acting Director for the Division of Policy Translation and Leadership Development at the Harvard T.H. Chan School of Public Health. For decades he held appointments as a Professor of Health Policy and Political Analysis at both the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School of Government. In addition, he directs the Harvard Opinion Research Program, which focuses on better understanding of public knowledge, attitudes, and beliefs about major social policy issues in the U.S. and other nations. He currently co-directs the Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health project on understanding Americans’ Health Agenda, including a joint series with National Public Radio and POLITICO. Previously, he co-directed a special polling series with The Washington Post and Kaiser Family Foundation. Additionally, Dr. Blendon co-directed a special survey project for the Minneapolis Star Tribune on health care that received the National Press Club’s 1998 Award for Consumer Journalism. He also co-directed a project for National Public Radio and the Henry J. Kaiser Family Foundation on American attitudes toward domestic policy. The series was cited by the National Journal as setting a new standard for use of public opinion surveys in broadcast journalism. In 2008, Dr. Blendon received the Warren J. Mitofsky Award for Excellence in Public Opinion Research from the Board of Directors of the Roper Center for Public Opinion Research at Cornell University. Learn more…
  • Bechara Choucair is an American administrator and chief community health officer of Kaiser Foundation Health Plan, Inc. and Hospitals. He previously served as senior vice president of Safety Net & Community Health at Trinity Health in Livonia, Michigan, and before that, was appointed Commissioner of the Chicago Department of Public Health from 2009 to 2014. Learn more…
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Interested in building toward a career on the front lines of Health Insurance? As you can see, there are many different avenues into this far-reaching issue. Use our Custom College Ranking to find:

Interested in diving into another one of our controversial topics? Check out The 25 Most Controversial Topics Today!

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