For all its technological breakthroughs and world-class medical research, the United States has never built a healthcare system designed to care for everyone. Unlike other wealthy nations whose modern health systems emerged from postwar movements for social solidarity, America’s system was shaped by a much older set of values, like hierarchy, exclusion, and racial inequality. Those values became embedded in the structure of public policy, and the consequences continue to define American health outcomes today.
What to Know…
The U.S. healthcare system was deliberately built on exclusion, shaped by racial ideology and political resistance, especially from Southern lawmakers who opposed any system that would require integrated medical care.
From the New Deal to modern reforms, race has shaped every major healthcare policy debate, influencing who receives coverage, how programs are structured, and why the U.S. never adopted universal care like other wealthy nations.
Contemporary disparities are a direct legacy of these choices, as recent cuts and political rhetoric continue to reflect long-standing beliefs about who is and is not “deserving” of care.
To understand why the United States stands alone among industrial nations without universal healthcare, we have to examine not just policy debates but the assumptions that guided them. At the center of the story is a painful truth: the American healthcare system was built to exclude, and racial ideology played a decisive role in that architecture.
Segregated from the Start
Throughout the first half of the 20th century, medical care in the United States was a segregated institution. Hospitals maintained separate wings, or separate buildings entirely, for Black patients. Many barred Black physicians from practicing. The federal government reinforced those divisions where early federal hospital standards allowed segregation, and federally funded facilities in the South routinely denied equal care to Black Americans.
This system was not dismantled until the Civil Rights Act of 1964, and even then, compliance was uneven. Segregated hospitals existed well into the late 1960s. By that point, the disparities were already deeply entrenched.
But the roots of exclusion began even earlier, in the debates surrounding America’s first major welfare programs.
The New Deal: A Safety Net with Gaping Holes
In the wake of the Great Depression, Franklin D. Roosevelt oversaw the most expansive social legislation in American history, the New Deal. Social Security, unemployment insurance, public jobs programs, and farm supports reshaped the federal government’s role in people’s lives.
But crucially, healthcare was absent. This wasn’t an oversight. It was a strategic omission.
Southern Democrats controlled powerful congressional committees and wielded enormous influence within the Democratic Party. They made clear that they would block any federal program that threatened Jim Crow segregation or the racial hierarchy underpinning Southern society. A national healthcare system, they feared, would force integrated facilities, equal access, and federal oversight, all unacceptable to lawmakers committed to maintaining white supremacy.
To secure their votes for Social Security and unemployment insurance, Roosevelt left healthcare out entirely.
Just as importantly, the programs he did include were carefully tailored to exclude many Black workers. Domestic labor and agricultural work, jobs disproportionately held by Black Americans, were initially left out of Social Security. The same political forces that barred Black workers from the economic protections of the New Deal also prevented the creation of nationalized medical care.
The result was an American welfare state built on racial compromise, and healthcare was sacrificed on that altar.
As the World Moves Toward Universal Care, America Moves Away
The end of World War II created unprecedented momentum for universal healthcare across the democratic world. The UK created the National Health Service in 1948. Canada built a system of public hospital insurance that expanded nationwide. Nordic countries implemented comprehensive national health programs.
The United States, however, doubled down on a different model, one that tied healthcare to employment. Employer-sponsored health insurance began as a workaround. During wartime wage freezes, companies offered health benefits to attract workers. After the war, policymakers embraced this system rather than create a public alternative.
This choice had profound consequences.
The jobs that offered health benefits were disproportionately held by white, male, middle-class workers, especially in manufacturing, unionized industries, and public-sector employment. Black Americans, marginalized into low-wage work by discriminatory hiring practices and educational inequities, were excluded by design.
As historians have noted, the American health system became universal for some, and structurally inaccessible for others.
Medicare and Medicaid: Progress, but with Built-In Inequality
The 1960s brought the first major federal effort to widen access: the passage of Medicare and Medicaid in 1965. Medicare provided universal coverage for adults 65 and older, regardless of race or income. Medicaid offered coverage to certain low-income Americans, though eligibility rules varied by state.
Again, race shaped the policy.
To get Medicaid through Congress, Southern lawmakers insisted the program be state-run, not federally administered. That structure allowed states to continue the discriminatory systems that had defined Jim Crow healthcare, with unequal access, underfunded hospitals in Black communities, and bureaucratic barriers that disproportionately targeted Black patients.
The same era brought a backlash that reshaped the nation’s politics. As the Civil Rights Movement dismantled legal segregation, a new political strategy emerged that attacked public programs through racially coded appeals. Terms like “welfare queen”, popularized by Ronald Reagan, allowed politicians to stoke resentment toward government aid by implying that Black Americans were undeserving beneficiaries.
Public support for health programs fractured along racial lines. Policies that might have expanded healthcare access were instead weaponized to inflame cultural divides.
Reagan and the Rise of Healthcare as Big Business
Ronald Reagan’s political identity was forged through opposition to federal healthcare programs. During the 1960s, he warned that Medicare would usher in socialism. When he became president in 1981, those ideological commitments shaped his administration’s approach.
Reagan cut public health budgets, loosened regulations on hospitals and insurers, and accelerated the privatization of care. These policies helped transform healthcare into one of the most profitable industries in America, but they also deepened disparities. Private hospitals grew. For-profit insurance expanded. Medical debt ballooned. Public health infrastructure eroded.
The wealthier and whiter the community, the better the care. The poorer and more racially marginalized the population, the more restricted the access.
That divergence continues today.
The Modern Era: The Same Old Arguments, New Packaging
Every modern attempt to expand healthcare, including Clinton’s reform plan in the 1990s, the Affordable Care Act in 2010, and the recent debates over Medicare for All, has encountered a familiar mix of racial resentment, ideological resistance, and corporate lobbying.
Opponents have shifted language away from overt racial coding, but the underlying narratives persist, claiming expanding healthcare will reward people who don’t work, don’t deserve it, or will burden “taxpayers”, a term often implicitly coded as white and middle class.
And the policy outcomes reflect those politics.
Those who oppose universal healthcare don’t want Americans to focus on how the U.S. spent $4.9 trillion on healthcare in 2023, which is equivalent to approximately $14,570 per person. This amount represented about 17.6% of GDP, or nearly one-fifth of the country’s total economic output.
The recently passed healthcare cuts championed as Trump’s “Big Beautiful Bill” represent the most significant reductions to health coverage in U.S. history. Estimates predict that 16 million Americans will lose healthcare, with disproportionate impacts on Black, Brown, and low-income communities.
As always, those with the least political power bear the heaviest burden.
A System Built on Exclusionary Values and Choices
America’s healthcare crisis is not an accident or a failure of policy imagination. It is the result of deliberate decisions shaped over generations, decisions rooted in the belief that not everyone is equally worthy of care.
Where other nations saw healthcare as a public good, the United States treated it as a privilege, a commodity, and a tool of social hierarchy. From segregated hospitals to employer-based insurance, from the New Deal compromises to modern political rhetoric, the message has been consistent: access to health is something to be earned, not guaranteed.
If Americans truly want a healthcare system that works for everyone, we must confront the values that built the one we have now. That requires more than policy reform. It demands a moral shift: a recognition that healthcare is not a reward for “deserving” individuals but a fundamental human right.
Other countries made that shift generations ago. The United States still can, but only if we acknowledge the truth about our past and choose a different path forward.
A healthcare system built on exclusion always produces inequality.
A system built on equality could finally deliver the care all Americans deserve.