We Were Never Meant to Have Universal Healthcare

The long, deliberate history of exclusion that shaped our healthcare system

Coretta Scott King (left, wearing sunglasses) leads a march in support of striking hospital workers through Charleston, South Carolina in 1969.(Lou Krasky / AP)

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Earlier this month, the Big Beautiful Bill, a sweeping federal spending package backed by Trump and the Republican party, was signed into law. And with its passing, it became the largest cut to healthcare in U.S. history. Independent estimates suggest that up to 16 million people could lose their insurance, many of them low-income families, children, and people with disabilities.

In the weeks since, I’ve noticed more people starting to question how our healthcare system works. In my comment sections, I keep seeing questions asking why our healthcare is largely tied to employment and why we don’t have a type of universal healthcare system like every other wealthy country in the world?

To understand that, we have to look at how our system was built in the first place. Because the history of U.S. healthcare policy is deeply shaped by race and power. And from the beginning, decisions about healthcare access have been tied to who was, and just as importantly, who was not, considered deserving of care.

Before Insurance

In the late 19th and early 20th century (before health insurance existed) there was no real “healthcare system” in the United States. Wealthy families typically paid out of pocket for a private physician, often calling doctors to their homes. For everyone else, options were limited.

Hospitals at the time were largely charitable institutions, often run by religious groups, cities, or counties. They were created because there was no other option for the poor. If you didn’t have money and needed urgent care, like if you had a heart attack or an injury, you could go to a public hospital and, in many cases, be treated. But the care you received depended heavily on your race, income, and where you lived.

These hospitals were underfunded, overcrowded, and in many parts of the country, segregated by law or practice. In the South, it was common for hospitals to deny care entirely to Black patients, forcing them to rely on under-equipped, segregated facilities or makeshift clinics staffed by Black physicians working with almost no institutional support.

This was also a time when medical care was far less advanced. Germ theory had only recently been accepted, antibiotics didn’t exist, and surgery was often dangerous. Most people didn’t expect to receive much, if any, effective treatment when they got sick. And outcomes were shaped more by income, geography, and race than by access to care.

It’s important to understand this baseline because the U.S. never had a moment when healthcare was designed as a public good for everyone. And from the beginning, it was treated as something you got if you could afford it or were deemed worthy of charity.

Racism And Universal Healthcare

Between World War I and World War II, there were several efforts to create a national health insurance system. And every one of them failed.

In the 1910s and 1920s, labor unions, progressive reformers, and public health advocates pushed for some form of public health insurance, similar to what was emerging in parts of Europe. But they ran into powerful opposition. The American Medical Association (AMA), fearing a threat to physician autonomy, framed public health insurance as “socialized medicine.” Private insurance companies and big business also lobbied against it, worried that government involvement would cut into profits or require them to contribute.

Then came the Great Depression. As millions of Americans lost their jobs, homes, and savings, the idea of a public safety net became more politically accepted and urgent. In response, Franklin D. Roosevelt introduced the New Deal, which was a sweeping set of programs designed to stabilize the economy, create jobs, and provide basic protections for struggling Americans.

One of it’s cornerstones was The Social Security Act of 1935, which created retirement pensions, unemployment insurance, and public assistance programs for the elderly, disabled, and poor. Many of FDR’s advisors also wanted to include a national health insurance program, but FDR made a calculated decision to leave it out.

He knew the politics were risky and wanted to ensure the other elements of the New Deal were able to pass. The AMA was already lobbying hard against government involvement in healthcare. But even more influential were Southern Democrats, who held key leadership positions in Congress. They feared that federal health programs, like hospitals receiving federal funds, might require racial integration or weaken their control over local systems that enforced Jim Crow segregation. And they strongly opposed universal healthcare because of this.

As a result, FDR left universal healthcare out of the New Deal. But this wasn’t the only compromise he made to appease the racist Southern Democrats. Many New Deal programs, like Social Security and the minimum wage, explicitly excluded agricultural and domestic workers, who were disproportionately Black. These exclusions were the direct result of negotiations with Southern lawmakers who wanted to preserve racial hierarchies and ensure that Black workers remained excluded from the protections of the modern welfare state.

So instead of building a public healthcare system as part of the New Deal, the U.S. opted to continue a patchwork approach, which left out the very people most in need by design.

How Employer-Based Health Insurance Took Over

By the time the U.S. entered World War II, most Americans still had no health insurance. But wartime policies changed that, largely by accident.

In 1942, the U.S. government created the Office of Economic Stabilization, which imposed wage controls to prevent inflation during wartime. As a result, employers were not allowed to raise wages to compete for workers, so they started offering benefits instead, including health insurance. Then in 1943, the IRS ruled that employer-sponsored insurance was exempt from federal income tax, making it cheaper and even more attractive for companies to offer. And within a few years, job-based insurance became the norm.

By the late 1940s, employer-sponsored insurance had become the dominant form of coverage for middle-class, mostly white, working Americans. But the people who were systematically excluded from these jobs, including Black and brown workers, women, part-time and agricultural workers, were largely left out. And because the U.S. had never built a public alternative, those gaps became entrenched.

Other wealthy nations took a different approach and in the wake of war, they moved to expand public healthcare. The UK created the National Health Service (NHS) in 1948, offering free healthcare to every resident, funded through taxes. Canada launched publicly funded hospital insurance in Saskatchewan in 1947, which grew into a nationwide, single-payer system by the 1960s. And in Sweden, the government expanded its publicly funded municipal health system throughout the 1940s and 1950s, eventually creating a national, tax-funded system grounded in the idea that healthcare is a universal right.

The U.S. went in the opposite direction. Instead of building a national system, it locked people into a model that made care conditional on having a job, with no fallback for those who didn’t have the right kind of job. And because the labor market was fundamentally shaped by racism, that system excluded millions of people, especially Black and brown workers, from the start.

The jobs most available to nonwhite workers at the time, like domestic and farm labor, were often excluded from health benefits, resulting in a healthcare system built on unequal access.

Expanding the Segregated Healthcare Infrastructure

After World War II, President Harry Truman proposed a national health insurance plan and a major expansion of hospitals to address glaring gaps in access. But Southern Democrats, who held powerful committee positions in Congress, demanded concessions to preserve racial segregation. The result was the Hill-Burton Act of 1946, which provided federal funding to build hospitals in underserved areas, while explicitly allowing segregation. It was the only federal law of the 20th century to do so. Southern states received priority funding and retained control over implementation, ensuring that new facilities could continue operating under Jim Crow laws.

While the number of hospitals increased, including some that served Black patients, the law reinforced a segregated system. Black physicians were routinely denied privileges at these hospitals and Black patients were either turned away or placed in under-resourced, separate wards. So although the federal government expanded healthcare infrastructure during this period, it did so in a way that preserved and deepened racial inequality.

The Partial Fix: Medicare and Medicaid

By the early 1960s, nearly half of Americans over 65 had no health insurance, and many were going without needed care. Rising medical costs were pushing more people into poverty, and civil rights activists were demanding an end to racial discrimination in hospitals and health access. There was growing momentum for government action.

Responding to this pressure, President Lyndon B. Johnson made healthcare reform a key part of his Great Society agenda, which was aimed at eliminating poverty and racial injustice in the United States. Some advocates pushed for a national, universal healthcare system, but LBJ knew that would face overwhelming opposition from the AMA, private insurers, and especially conservative Southern lawmakers (overwhelmingly Southern Democrats at the time). So instead, he pursued a more politically viable path and targeted programs specifically for the elderly and the poor.

In 1965, Johnson signed Medicare and Medicaid into law. Medicare provided health coverage to people over 65, regardless of income, and was federally administered. Medicaid was created to cover some low-income Americans, including children, pregnant women, and people with disabilities, but it was a means-tested program, and states were given control over how it was implemented.

That distinction mattered because southern lawmakers only agreed to Medicaid on the condition that it would be state-run, which allowed them to maintain local control and continue the racially discriminatory practices that defined Jim Crow-era healthcare. Medicare, by contrast, was federally administered, which meant hospitals had to desegregate in order to receive federal funds. And because of this, in practice, Medicare became one of the most effective civil rights enforcement tools of the 1960s, forcing thousands of hospitals to end segregation in a single year.

Still, these programs weren’t designed to be universal. They created new tiers where if you were old enough, poor enough, or disabled enough, you got coverage. Everyone else stayed in the employer-based system, or went without. The lines that divided who got care and who didn’t were fundamentally shaped by race, class, and political compromise, and they’re still with us today.

Political Backlash From the Great Society

After the passage of Medicare and Medicaid in 1965, there was widespread recognition that the programs filled a critical gap, but the political will to go further faded quickly.

The backlash to LBJ’s Great Society, including the civil rights legislation, anti-poverty programs, and expanded federal role that came with it, was strong. Many white voters, especially in the South and suburbs, began to see federal programs as redistributive and helping “others” at their expense. And conservative politicians seized on that shift. They framed programs like Medicaid and food assistance as examples of government overreach and waste, tapping into racial resentment and anti-tax sentiment.

In the years that followed, many white Southern Democrats, angered by the Democratic Party’s support for civil rights and desegregation, began shifting their allegiance to the Republican Party. And Republican politicians increasingly appealed to them with racially coded language, promising to restore “law and order,” cut government spending, and end so-called welfare abuse. This political realignment reshaped the parties and laid the foundation for decades of resistance to expanding the social safety net.

And throughout the 1970s and 1980s, the political mood shifted decisively. Ronald Reagan, who had launched his political career in the 1960s by warning that Medicare would lead to socialism, rose to power by promoting a vision of limited government, personal responsibility, and lower taxes. By the time he became president in 1981, the idea of expanding public healthcare had become politically toxic in many circles.

While he didn’t attempt to repeal Medicare, which by then was too popular, President Reagan significantly reshaped the healthcare landscape. His administration cut federal funding for public health programs, deregulated hospitals and health systems, and pushed to reduce the federal government’s role in healthcare delivery—accelerating the rise of corporate, profit-driven medicine. Federal support for public hospitals and community clinics declined sharply, leaving many low-income communities with fewer options. At the same time, safety net programs were increasingly framed as bloated and wasteful, and public rhetoric, often racially coded, cast recipients, especially poor Black women, as “welfare queens” gaming the system. That image became a potent political tool, reshaping public perception of government assistance as something abused by the undeserving rather than a vital support for the vulnerable.

By the 1990s, when President Bill Clinton, who won the presidency as a centrist Democrat, attempted to pass a national healthcare plan to address rising costs and growing instability in coverage, it was met with fierce resistance from insurers, Republicans, and business interests. By then, in part as a result of Reagan-era policies that deregulated hospitals and encouraged market-driven reforms, healthcare had become big business where hospitals were consolidating into multi-state systems, insurance companies had merged into industry giants, and pharmaceutical companies had gained enormous pricing power. These corporate interests had become major political players, lobbying aggressively against reforms that threatened profits. Clinton’s plan failed so badly that it didn’t even make it to a vote, and many analysts believe it was a major reason Democrats lost control of Congress in 1994, in what was called the Republican Revolution.

Ultimately, for nearly half a century after Medicare and Medicaid passed, the U.S. did nothing to significantly expand public coverage. Instead, it doubled down on a fractured, employer-based system rooted in racial and economic exclusion that only became harder to overcome as private insurers, pharmaceutical companies, and hospital systems became more powerful and coverage gap disparities strengthened over time.

The Affordable Care Act

By the late 2000s, the disparities in the U.S. healthcare system had widened even further. Nearly 50 million Americans were uninsured, and many more were underinsured. After decades of political silence on healthcare reform, Barack Obama made it a central issue in his 2008 campaign, framing it not as a radical overhaul, but as a moral and economic necessity.

The result was the Affordable Care Act (ACA), a landmark reform signed into law in 2010. It wasn’t a universal healthcare system, and it didn’t eliminate private insurance, which was an intentional political calculation aimed at expanding healthcare coverage within the constraints of the political climate at the time. Still, it was the most significant expansion of healthcare access since Medicare and Medicaid.

The ACA:

• Expanded Medicaid eligibility in participating states

• Created insurance marketplaces with income-based subsidies

• Banned insurers from denying coverage due to preexisting conditions

• Allowed young adults to stay on their parents’ plans until age 26

All told, more than 20 million people gained insurance through the ACA.

But the backlash was incredibly strong. Conservative media and politicians framed it as a government takeover, even though it relied heavily on private insurers, and the fact that it was passed under the first Black president only intensified the political resistance. The Tea Party movement emerged in response, mobilizing around anti-government, anti-tax, and racially charged opposition to “Obamacare.”

Republicans began calling for the repeal of the ACA almost as soon as it was signed into law in 2010. That November, in the 2010 midterm elections, the GOP rose to power in the House of Representatives, largely by campaigning against “Obamacare.” It was a major blow to the Obama administration, and it marked the beginning of a relentless effort to dismantle the law.

Over the next several years, Republicans in Congress voted to repeal or defund the ACA more than 60 times. Most of those efforts were symbolic, blocked by the Democratic-controlled Senate or vetoed by Obama. But they kept the issue alive, fueling conservative media and galvanizing the Republican base.

When Donald Trump won the presidency in 2016, Republicans finally had control of both Congress and the White House. In 2017, they came close to a full repeal, but the effort famously failed by a single vote in the Senate, with Senator John McCain casting the deciding “no.”

Still, they succeeded in eliminating the ACA’s individual mandate, which required that most people have insurance or pay a penalty. That change, passed as part of Trump’s 2017 tax bill, destabilized insurance markets, especially in states that hadn’t expanded Medicaid. Premiums rose in many areas, and enrollment declined in subsequent years. But the sharp drop that many analysts predicted never fully materialized, partly because subsidies remained intact, and later, the COVID-19 pandemic prompted new enrollment surges and federal protections that helped stabilize coverage again.

COVID, Biden, and a Temporary Expansion

When Joe Biden took office in 2021, the U.S. was in the midst of a public health crisis. The pandemic had also exposed the cracks in the healthcare system when millions lost employer coverage, hospitals were overwhelmed, and racial health disparities continued to be evident.

In response, the Biden administration passed the American Rescue Plan, which temporarily expanded ACA subsidies, extended eligibility to more middle-income Americans, and offered incentives for states to expand Medicaid. These changes helped drive ACA enrollment to record highs—more than 21 million people signed up in 2024—and pushed the uninsured rate to a historic low of 7.7%.

For a moment, it looked like the U.S. was building a stronger safety net. But most of these gains were temporary. When pandemic protections ended in 2023, states began removing people from Medicaid rolls, and over 20 million people lost coverage, often due to red tape, not income changes. Meanwhile, 10 states still refused to expand Medicaid, leaving millions in a coverage gap where they were too poor to qualify for ACA subsidies but ineligible for Medicaid under state rules.

Biden had campaigned on adding a public option, similar to the one President Obama initially wanted but ultimately dropped in order to pass the ACA. But with narrow Senate margins and opposition from moderate Democrats, his administration focused on protecting the ACA, rather than overhauling the system and attempting to include a public option.

Then, in 2025, the political energy shifted again.

Present Day

In 2025, Donald Trump returned to office with a Republican-controlled Congress and signed the Big Beautiful Bill into law, which was a sweeping package that delivered massive tax cuts to corporations and the wealthy, while enacting the largest healthcare cuts in U.S. history.

As part of the law, Medicaid funding was slashed, ACA subsidies were rolled back, and an estimated 16 million people are expected to lose insurance. And just like before, the people most at risk are those already facing structural barriers, including low-income families, disabled individuals, and communities of color.

So how did we get here?

Why, unlike every other wealthy nation, does the U.S. still not have a universal healthcare system?

The answer runs through everything you've just read. From the beginning, American healthcare wasn’t built to cover everyone and was intentionally built to exclude specific people. It was shaped by racism, labor market exclusions, and political compromises that defined who was “deserving” of care. Over time, the language changed from overt racism to talk of “welfare dependency,” “government overreach,” or “personal responsibility,” but the underlying logic that not everyone should have access stayed the same.

We didn’t arrive at this system by accident. It was built through deliberate choices driven by deeply held beliefs about who deserved care and who didn’t. From the beginning, decisions about healthcare access were shaped by values that prioritized some lives over others. And that legacy still defines our system today.

And if we want a different system, we’ll have to confront those values and choose differently.

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Author’s Note:

This article is a broad overview of how the U.S. healthcare system was intentionally shaped by decisions rooted in race, power, and political compromise. It’s far from exhaustive. The history is deep and complex, and entire books have been written about it. If you’re interested in going deeper, here are a few good books I’ve read and recommend:

Health Care for Some: Rights and Rationing in the United States Since 1930 by Beatrix Hoffman

The Social Transformation of American Medicine by Paul Starr

Medical Apartheid by Harriet A. Washington