most obvious ones. Moreover, it shows that the calculations each employer
makes and the conclusions it reaches on the subject may be somewhat
different. The authors hope this analysis and exposition will make those
calculations easier and the conclusions reached more likely to be the right
V. CONCLUSION: WHAT WILL THE FUTURE BRING?
This paper has tracked the evolution of employment-based health
insurance in the U.S. from its earliest days to the present and attempts to
project its path into the future. This final section draws these evolutionary
steps together into a conceptual framework to help readers evaluate and
project for themselves what the future will bring.
To properly understand our pluralistic, disjointed healthcare system, one
has to recognize that, unlike other major nations that have had UHC for
many years, the U.S. system did not grow as a coordinated government-directed program. Rather, it evolved over roughly a century through a
countless number of independent choices. 202 Our system is in many
respects a “non-system,” but just because it’s uncoordinated and disjointed,
one cannot assume it’s easy to change. It is held together by an extensive
and intricate web of private arrangements, decisions, relationships, and
economic interactions. Because these links were independently developed
and put in place at different times, they are harder to dismantle and replace
with something new – and that’s even without considering the myriad of
political barriers that would have to be surmounted to accomplish major
systemic change. The Gordian knot nature of things has made healthcare
reform an exceedingly difficult task, one that has taken such a long time and
is still far from being achieved.
The ACA, by strengthening the health insurance marketplace and
requiring insurers to make adequate coverage available to all on a more
affordable and non-discriminatory basis, has largely undercut the rationale
and necessity for EBHI. Nevertheless, the ACA hasn’t simply done away
with employment-based coverage, because it couldn’t. Our healthcare
system is resistant to change because it has evolved in a way very much in
sync with “the American way” of doing things. As a people we value
choice; we don’t want anyone telling us what to do—and, for a large
202. Note, though, that government actions - such as the passage of Medicare,
Medicaid, the HMO Act, ERISA, the Internal Revenue Code provisions granting favored
treatment to employer provision of health benefits and, of course, the ACA - very much
created the context and opportunity for many free market developments. For an excellent
analysis of this interplay between government actions and private initiatives, see ROBERT I.
FIELD, MOTHER OF INVENTION: HOW THE GOVERNMENT CREATED “FREE-MARKET” HEALTH
CARE (Oxford U. Press, 2014).