Throughout the 2010s, the changes brought about by the ACA did little to make health care better or to improve the health of the nation. The budget sequestration in late 2012 led to draconian cuts that paralyzed many government agencies, created business uncertainty, and sparked a recession worse than what Europe was suffering. Unemployment peaked at 14 percent in 2014. Medicare was “modernized” in 2014 with vouchers for those turning 65 beginning in 2020 and with payment cuts that made it difficult for those already over 65 to find providers willing to accept them.
Society fragmented into demographic, ethnic, and economic factions, each of which looked out for its own interests at the expense of the others. With an ever growing gulf between the “haves” and the “have-nots,” the affluent cared little about society’s most vulnerable, the ranks of which expanded every year as unemployment bounced up and down around an average of 10 percent. In periods of economic growth, more than 95 percent of new wealth was captured by the richest 5 percent. In periods of economic decline, the poorest 50 percent experienced the greatest suffering.
Spiritual health eroded as hope turned to despair. The optimism for which Americans were once known became a pronounced pessimism over a political and economic system that no longer seemed to care about the poor and middle class. Social health declined terribly for families and communities, as the psychosocial burden of illness spread apathy, fed further economic malaise, and diminished Americans’ desire to interact with one another. Psychological and behavioral health got worse as depression and substance abuse became ever more entangled problems feeding off each other. Economic downturns saw many people lose their jobs, homes, and hopes and then start turning to junk foods, alcohol, and drugs for relief. Heart disease, cancers, and diabetes all became more prevalent, with incidence rates increasing for youth as well as for elders.
The political consequences were pronounced: the center did not hold and elections oscillated between extremes as policy battles raged over health care, energy, climate change, immigration, taxes, and budgets. Each election cycle was more passionate and less reasoned than the last, and while each political party blamed the other, neither could govern effectively. Americans became increasingly alienated from a process that consistently produced divided governments in which the minority sabotaged any majority-led legislative effort, often using arcane rules and procedures. As a result, national politics were at best ineffective and at worst toxic, with major policy decisions increasingly made by the Supreme Court, often by narrow majorities.
In this political context, the national government was unable to address the crisis in health care. Federal entitlement programs had been enlarged with good intentions, but resources remained stagnant and forced agencies to limit – and in some cases even ignore – actions they were legally bound to carry out. State governments were similarly unable to address the crisis given their own fiscal constraints and the massive cuts to government services that they had already enacted. By 2020, 75 million Americans were uninsured, while the great majority of Americans were underinsured. Yet the cost of care continued to grow as hospital costs increased and the ability to constrain fees diminished outside the integrated systems used by the well-insured.
Among health care providers, the business ethic of profitability trumped long-standing medical ethics. Physicians drove their own revenues by ordering tests and procedures with little value for health, and many became co-owners of the hospitals and laboratories where these services were delivered as previous restrictions were overturned by free market advocates. To tighten their stranglehold on the delivery of care, physicians organized through well-funded networks to have states sanction their competitors among complementary and alternative medicine (CAM) practitioners, nurse practitioners, retail clinics, online services, and personal health avatars. States also had to fight against a growing “back alley” medical industry that provided care at highly variable levels of quality. Further, medical associations aggressively lobbied the Department of Health and Human Services to cut federal funding for community health centers, which as the “health care provider of last resort” had achieved high standards of quality and were taking more business from private practice physicians. Thus it became harder for the poor to find good care and easier to be sold bad care.
While some U.S. consumers were able to discern between good care and bad, many affluent or well insured consumers sought care overseas when they needed major medical procedures. India, Singapore, Mexico, and several other countries built successful medical tourism industries to meet this need. This further challenged U.S. hospitals for some of their best paying business. In addition, new diseases and bacteria – some of them antibiotic-resistant – emerged to find hospitable environments in the U.S. in the wake of global climate disruption. Infectious disease epidemics, including infections acquired in hospitals, spread even among those in “good” care systems, while the toll on the uninsured was far worse.
The suffering experienced in low income areas was immense, and could be measured in terms of reduced life expectancy and declining health status. Poor and minority populations with the highest rates of obesity, diabetes, preventable cancers, and drug-resistant infectious disease were generally blamed for their own ill health. Sensationalistic media and misleading measures of community risk had fed into an “us versus them” narrative that stigmatized the sick and thus further marginalized poor and minority populations. Some ethnic populations were scapegoated as having overburdened the health care system with their unhealthy cultural norms. If someone was sick, he or she was often better off hiding it to avoid further discrimination.
Of course, not all news in health and health care was bad. Remarkable advances in science offered new treatments that could decisively address many diseases. Targeted drugs based on a molecular understanding of disease pathways meant that many cancers and Alzheimer’s could be controlled. The revolution in molecular biology combined with an information infrastructure that supported increasingly personalized treatments using genomics, proteomics, and microfluidic diagnostics to identify disease long before patients felt a symptom. Yet the high cost of these technologies kept markets small and allowed only those with means to receive the great benefits of 21st century science.
For the others, health care was limited to what could be obtained in the fee-for-service “minute clinics” run by large retail chains, or from online services, many of which were offering free – and often substandard – treatment advice. Some providers still accepted Medicare and Medicaid vouchers, but cuts in these programs hastened retirement of those physicians who could retire. Those who refused the reduced payments from Medicare and Medicaid went out of business unless they had affluent patients or affiliated with an organization that could help them get paid. With the worsening provider shortage, community health centers were inundated by individuals and families seeking high-quality, affordable care. Health care spending had dropped to 17 percent of GDP, but only because of cuts in Medicare and Medicaid payment levels and because many Americans had decided to forgo care or to find care overseas. Poorer Americans in particular were frequently forced to go without. By the mid-2020s, health for most Americans was measured not in terms of wellness but by the absence of debilitating disease, from which the poor had little real protection.
Despite the aggregate national decline in health, some successes could be found in so-called “transition communities” that explicitly strengthened community bonds and addressed social inequities. These communities, which proactively pursued alternatives to expensive oil-based energy, fostered initiatives to address the social determinants of health, in particular through community agriculture and home food production, lower-cost and sustainable energy and housing, and better but low-cost education, particularly for low-income people. These communities often thrived in areas beyond health, particularly as they emerged as hubs of innovation and economic dynamism.
By 2027, the stark difference in health status between rich and poor created a national outcry, fed by media personalities and by researchers whose clear evidence of the negative impact of past policies served as an indictment of many policymakers in the eyes of the public. The growing engagement of UN health agencies and global development NGOs in poor communities in the U.S., as well as the success of “bottom of the pyramid” innovations from the developing world, became a source of national shame. Responding to this outcry for basic fairness, the President demanded, and the Congress passed, legislation to create a single-payer health care system in 2028, with the mandate to lower cost and enhance quality so that all Americans will have access to basic care.
However, the legislation left it to CMS to work out the details. Medical experts still struggle to sift through two decades’ worth of often biased comparative effectiveness research, while health economists try to envision a payment system that can rein in a highly disparate delivery system. A government task force has recommended new investments to salvage the billions misspent on the nation’s patchwork of computer-based medical records. Four years later, in 2032, many remain skeptical that the U.S. will ever be able to afford the level of disease it has created. And many do not believe that the long-awaited single-payer system will finally resolve the U.S. health care crisis.