HJNO Nov/Dec 2025

HEALTHCARE JOURNAL OF NEW ORLEANS I  NOV / DEC 2025 9 service generated a bill, to a more collective, “we-based” arrangement in which cost and risk were shared across a group. While HMOs would later become controversial, the 1973 act reflected an early recognition that unchecked fee-for-service care was unsustainable and that structural reform required new models of shared responsibility. However, when HMOs failed to bring cost and access problems under control, the 1990s brought the Clinton administration’s own failed effort at national health reform, then derided as “Hillarycare.” Opponents again cast it as big-government overreach, and it ultimately collapsed under partisan rancor. In contrast, Massachusetts, under Governor Mitt Romney, enacted near-universal coverage in 2006 using an individual mandate, laying the groundwork for the subsequent Affordable Care Act (ACA) of 2010. An often-overlooked irony in the story of American healthcare reform is that the intel- lectual foundation for Massachusetts’ landmark 2006 law — or “Romneycare” — came from the conservatively oriented Heritage Foundation. 5 As far back as 1989, Heritage scholar Stuart Butler argued that individuals should carry a personal responsibility to maintain health insur- ance coverage, much like state requirements for auto insurance. This individual mandate be- came the central feature of the Massachusetts reform, paired with Medicaid expansion and subsidized private insurance exchanges. How- ever, when the Affordable Care Act adopted the same framework in 2010, opponents derid- ed it as government overreach, derisively label- ing it “Obamacare” — even though its origins lay in a conservative think tank’s effort to avoid single-payer models. The fact that an idea born in conservative circles became a lightning rod for partisan division underscores how profoundly the politics of healthcare had shifted from shared problem-solving to entrenched ideological camps. The ACA had reignited the national fight over healthcare as a right versus a privilege. Supporters of the ACA hailed it as the most significant step toward healthcare since Medicare and Medicaid; critics lambasted it as a government takeover of healthcare. 6 vision, however, never advanced beyond rheto- ric. Harry Truman carried the torch after World War II, proposing a universal health insurance system, but the plan faltered under accusations of “socialized medicine” and fierce opposition from the American Medical Association. 2 The creation of Medicare and Medicaid in 1965, led by President Lyndon Johnson as part of his Great Society agenda, marked a historic compromise: coverage for the elderly and the poor, but not for the working-age population. 3 It is worth remembering that the Social Secu- rity Amendments Act, which created Medicare and Medicaid, passed with bipartisan support. While the bulk of the support came from John- son’s Democratic majority, a meaningful share of Republicans joined as well, making the cre- ation of these landmark programs a genuinely bipartisan effort. That stands in sharp contrast to more recent healthcare legislation such as the Affordable Care Act, which passed in 2010 without a single Republican vote in either chamber. The comparison underscores how the political climate surrounding healthcare has shifted from opportunities for cross-party con- sensus to a zero-sum, us-versus-them struggle. In the 1970s, because of rising healthcare costs despite many people remaining unin- sured, Richard Nixon championed the idea of HMOs, arguing that private market competi- tion could control costs and expand access. 4 The Health Maintenance Organization Act of 1973 provided federal incentives and support for networks of providers to come together and offer discounted pricing, as long as patients received their care within these “narrow” net- works. These HMOs attempted to control costs by restricting access to a pre-approved group of providers, and although these plans empha- sized preventive care and care coordination, they also introduced gatekeeping mechanisms that limited patient choice and sometimes de- layed necessary treatment. Employers, facing soaring premiums, came to embrace HMOs and preferred provider organizations (PPOs) as cost-cutting alterna- tives to traditional fee-for-service insurance. By encouraging pooled financing, the HMO Act embodied a subtle shift from a strictly individu- alistic, “me-based” transaction in which every As we continue our exploration of what’s wrong with healthcare, we’ve examined the history and soul of health insurance, scrutinized our own role as providers, and looked closely at the payer–provider tension in utilization man- agement. Up to this point, the focus has been on how structural incentives and misaligned practices distort care delivery. This next install- ment turns to something broader: how Amer- ica’s political, cultural, and structural divisions shape our understanding of healthcare itself. Dr. Paul Farmer, the physician immortalized in Tracy Kidder’s book Mountains Beyond Moun- tains , embodied the conviction that medicine is inseparable from social justice. His work in Haiti and around the world exemplified what it means for a physician to strive for a cause greater than self — health as a human right, pursued with relentless commitment to equity and inclusion. Farmer’s example reminds us that healthcare is not merely a set of transac- tions, but a reflection of our values and our will- ingness to act in solidarity with one another. It is an apt starting point for this article because at the heart of America’s healthcare debate lies a fundamental question: Is healthcare a guaran- teed right or an earned privilege? Healthcare as Right vs. Privilege Few questions divide Americans as sharply as whether healthcare is a right or a privilege. We touched on this topic briefly in part 3 of this series. If it is a right, then society bears respon- sibility for ensuring access, much like public education or police and fire protection. If it is a privilege, then healthcare becomes contingent — something earned through employment, wealth, or personal responsibility. This debate is not new. Franklin Roosevelt envisioned health coverage as part of his “Sec- ond Bill of Rights” in 1944. He argued that the original Bill of Rights, which guaranteed politi- cal liberties, was no longer sufficient to ensure true freedom and the “pursuit of happiness” in a modern industrial society. Also known as the “Economic Bill of Rights,” the Second Bill of Rights sought to ensure basic economic security for all Americans. Roosevelt proposed that “the right to adequate medical care” should be guaranteed for all citizens. 1 His “Medicine should be viewed as social justice work in a world that is so sick and so riven by inequities.” — Paul Farmer