A few years ago, a student in my Public Health History course asked why her mother couldn’t afford insulin without insurance despite having a full-time job. I told her what I wanted to believe: America's health care system was built on purpose.

People often hear about health care dysfunction in the United States - too expensive, too complex and too unfair. But dysfunction means failure. What if the real problem is that the system is operating completely rationally with the design? Understanding this legacy is key to explaining why reforms fail repeatedly and why change remains so difficult.

I am a historian of public health and have experience studying the differences in oral health access and health care in the Deep South. My focus is on how historical policy choices continue to shape the systems we rely on today.

By tracking the roots of today’s systems and all of their problems, it’s easier to understand why health care in the United States looks like it, and reform it into a system that provides high-quality, affordable care for all. Only when faced with how profits, politics, and prejudice shape the current system can Americans imagine and demand distinction.

Decades of compromise

My research and many other studies show that today’s high cost, profound inequality and decentralized care are predictable characteristics developed from decades of policy choices that prioritize profits over people, ingrained racial and regional hierarchies, and view health care as a commodity rather than a public interest.

Over the past century, health care in the United States has not evolved from a shared universal care vision, but rather from a compromise to prioritize private markets, protect racial hierarchies and increase individual responsibility rather than collective well-being.

Employer-based insurance emerged in the 1940s not from a commitment to workers’ health, but from a tax policy solution during wartime wage freezes. The federal government allows employers to provide tax exemptions and incentive coverage while avoiding state-owned care. This decision will allow healthy access to employment status, a structure that remains dominant today. By contrast, many other countries with employer-provided insurance paired with strong public options to ensure access is not only relevant to work.

In 1965, Medicare and Medicaid greatly expanded the public health infrastructure. Unfortunately, they also reinforce existing inequality. Medicare is a federal government management program for people over 64 years of age, which mainly benefits wealthy Americans who can get stable, formal employment and employer insurance while working. The Medicaid program designed by Congress as a federal national program is targeted at the poor, including many people with disabilities. The combination of federal and state oversight leads to 50 different programs and has a wide range of qualifications, coverage and quality.

In particular, the Southern legislators fought for this decentralization. They are trying to maintain control over those who receive benefits due to concerns about federal oversight of public health spending and civil rights enforcement. Historians show that these efforts are primarily intended to limit access to health care benefits in races during Jim Crow.

Swelling bureaucracy, "crawling socialism"

Today, this legacy is visible.

The states that chose not to expand Medicaid under the Affordable Care Act are located in the southern part of which includes some large black populations. One in four uninsured black adults who are uninsured are trapped in coverage – not able to access affordable health insurance – they earn too much to qualify for Medicaid but not enough to get subsidies through the Affordable Care Act market.

The system's architecture also hinders care targeted to prevent. Because Medicaid’s scope is limited and inconsistent, preventive care screening, tooth cleaning and chronic disease management often fall into cracks. This leads to more expensive post-care, further burdening hospitals and patients.

Meanwhile, cultural attitudes such as “strong individualism” and “freedom of choice” have long been deployed to resist public solutions. In the decades after the war, European countries established national health care systems and the United States strengthened market-driven approaches.

American politicians and industry leaders increasingly portray threats of publicly funded systems that threaten individual freedoms – often seen as signs of “social medicine” or socialism’s spread. For example, in 1961, Ronald Reagan recorded a 10-minute LP titled “Ronald Reagan Against Social Medicine”, distributed by the American Medical Association as part of a national effort to block Medicare.

The administrative complexity of the health care system began in the 1960s, due to the rise of state-owned Medicaid, private insurance companies and increasingly fragmented billing systems. Patients are expected to browse opaque billing codes, networks and formulas while trying to treat, manage and prevent disease. I think this is not accidental, but a profitable form of chaos built into the system to benefit insurance companies and intermediaries.

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Coverage, chronic withdrawal

Even good-willed reforms have been established on this structure. The Affordable Care Act, passed in 2010, expanded access to health insurance, but retained many of the system's fundamental inequalities. By subsidizing private insurers rather than creating public options, the law strengthens the central role of private companies in the healthcare system.

Public Choice - a government insurance program designed to compete with private insurers and expand coverage - was eventually stripped of the Affordable Care Act during negotiations due to political opposition from Republicans and moderate Democrats.

When the U.S. Supreme Court became optional in 2012 to enable states to provide expanded Medicaid coverage to low-income adults, earning up to 138% of federal poverty levels, it expanded the inequality that the ACA is trying to reduce.

These decisions have consequences. In states like Alabama, where an estimated 220,000 adults are still uninsured due to the gap in Medicaid coverage, this is a recent year of reliable data – highlighting the ongoing impact of the state’s refusal to expand Medicaid.

Additionally, rural hospitals have been closed, patients have given up care, and there is a lack of practice in the entire county of ob/gyns or dentists. And, when people do get cared for, especially in states where many people don’t have insurance, they can accumulate medical debt that can drive their lives.

All of this is caused by chronic investment in public health. The federal funds prepared for emergency have been inadequate for many years, with local health departments underfunded and understaffed.

The COVID-19 pandemic has revealed the vulnerability of infrastructure – especially in low-income and rural communities where overwhelmed clinics, delayed testing, limited hospitalization and higher mortality have exposed the fatal consequences of neglect.

Design the system

Change is difficult, not because reformers have never tried it before, but because of the interest of the system aiming to provide services to it. Insurance companies profit from obscure networks - transfer networks, obfuscated configurations, bill codes that few people will decipher. Providers profit from a paid service model that will reward quantity rather than quality, prevention procedures. Politicians harvest campaign contributions and avoid blaming for proliferation and reasonable deniality through delegations.

This is not an accidental dysfunction network. It is a system that turns complexity into capital and bureaucracy into obstacles.

Patients (especially uninsured and underinsured) are unlikely to make choices: delay treatment or take on debt, ration medication or skip examinations, trust the health care system or not bring. At the same time, I believe that choice and freedom of speech obscures the limitations of choice for most people.

Other countries show us that alternatives are possible. The systems in Germany, France and Canada vary greatly in structure, but all of them prioritize universal access and transparency.

Understand that the U.S. health care system is designed to achieve meaningful changes, rather than assuming it fails unintentionally.