How Would Darwin Fix US Healthcare?
Evolutionary lessons from flightless dodos and the shriveled appendix
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In early March 2020, just before the COVID-19 shutdowns, former President Obama sounded pensive discussing the state of healthcare in America. Ten years after the Affordable Care Act (ACA) passed, he recognized things could have turned out better. But speaking to journalist
, he defended the choice to work within the “legacy system” and not “dismantle that entire system ― or even transition it entirely ― to a single payer system, [which] looked politically impractical and probably really disruptive.” He was right. Even though Washington DC sapped the ACA’s ability to reform US healthcare, such incremental measures still offer hope.
A predominantly employer-sponsored health insurance system no longer serves the US today. In 1980, 70% of workers received health insurance from their employers; by 2010, that number had fallen to 53%. A larger proportion of the US population is now either retired or self-employed. Upwork estimates 36% of Americans worked as full time freelancers in 2020, nearly doubling since 2014.
Even for those who have access to health insurance, costs have spiraled. Large private insurance companies wield most of the market power. The average family premium for coverage through an employer increased 47% between 2011 and 2021, from $15,073 to $22,221. And in the same timeframe, average deductible increased 92% from $747 to $1,434. A quarter of American adults owe more than $5,000 in healthcare debt.
’s insightful posts on explore these themes.Hence, proponents of major structural reform, like Bernie Sanders, see the current systems as irreparably broken. To use a trite analogy from evolutionary biology, US healthcare looks a lot like the flightless dodo.
Dodo Healthcare
Those birds had evolved, without predators in their elysian home, Mauritius. They grew fat deposits and conserved energy by nesting on the ground, traits that helped them survive the winter. The arrival of humans and their pets on the island’s beaches, however, changed everything. Those same fat deposits now attracted predators. There was not enough time for the Dodo’s to evolve other traits to survive in the new environment. Dodo’s couldn’t just lose fat deposits and migrate by flight. The entire dodo population was wiped out.
Similarly, the US healthcare system is maladapted to the needs of this century. In the 1920s, as modern medicine and hospitals emerged, so did new health insurance companies. These fledgling insurance providers looked to employers as potential purchasers of benefits for their employees. The idea was attractive. A single customer could bring many subscribers reliably into a new insurance program.
This model truly found its footing during the Second World War. As millions of American men went to war, employers were having trouble finding workers. Fearing spiraling inflation, the federal government imposed wage and price controls. So, employers couldn’t raise wages, and turned to other benefits. Employer-sponsored private health insurance started flourishing in the early 1940s.
Although there was early competition from proposals for universal healthcare by FDR and Truman, political waves entrenched the private insurance system. Resistance came from cold-war era fears of communism, racial bias (a government run plan would have disproportionately benefited African Americans in lower income brackets), and lobbying by the formidable American Medical Association, which feared government-imposed price controls.
For the next few decades, Congress added some garnish, like the implementation of Medicare and Medicaid in 1965. But the core structure was largely undisturbed.
An Alternative Evolutionary Transition
So, is our healthcare system evolutionarily trapped? Borrowing a leaf from a different kind of evolutionary transition may be instructive.
Extinctions are not the only fate of evolutionary mismatches. Traits that were the result of adaptation for one purpose can often be transformed to serve often unrelated purposes in future generations. In 1982, evolutionary biologists Stephen Gould and Elisabeth Vrba coined the term “exaptations” to describe beneficial features that were “not built by natural selection for their present role.”
Researchers now believe that exaptation is a much more common route for the evolution of new traits from maladapted ones, than previously believed. The human appendix, for instance, was long believed to be a vestigial organ. It is a remnant of a part of the colon in our ancestral species which helped digest cellulose from leaves and grass. One of the only noteworthy properties was thought to be its susceptibility to appendicitis, an incredibly painful inflammation. However, recent studies suggest that the appendix may have in fact been exapted to serve as a rich repository for beneficial gut bacteria. Now, it could help provide protection to humans against dangerous stomach infections.
The Affordable Care Act was an attempt to do something similar for US Healthcare. Obama hints at the evolutionary process they had in mind:
“You get the program started, you figure out what the kinks are, what works, what doesn’t. You amend, build, improve, refine ― that kind of iterative process, where you’ve set a goal and gotten the foundations laid, and then Congress in a cooperative fashion works to keep making it better. That process, which is very beneficial because you’re getting real data and feedback about what’s working and what’s not...”
What the ACA Attempted
Building upon the prevailing healthcare structure, the ACA brought millions of more people in by expanding Medicaid, ensuring insurance coverage for people with pre-existing health conditions, extending subsidies for low-income individuals through new online health exchanges, and mandating everyone to sign up for insurance.
In the vein of repurposing existing features, ACA expanded the scope and function of Medicaid coverage. The federal government increased subsidies received by states that opted in. There, Medicaid covered people up to a higher income level, and unlike the prevailing policy in most states, even if they were “able-bodied.” This was a small step towards more universal care, though implemented within the American federal structure.
The new law also created health insurance exchanges, online marketplaces, where unemployed or self-employed individuals could more easily sign up for insurance plans. Employers would no longer be the only customers for insurance companies. These changes helped spread coverage costs more effectively across a wider population, enabling more affordable healthcare for many more people.
Despite these advances, the ACA’s effectiveness was blunted when, during negotiations in Congress, it lost one of its most powerful new proposed features: a public healthcare option.
’s 2021 book vividly depicts the dramatic, and ultimately failed negotiations with moderate- and conservative-leaning US Senators. A public option would have allowed a government-run health insurance plan to compete in the marketplace with private insurance companies.Kathleen Thelen, Ford Professor of Political Science at MIT, described the removal of the public option from the ACA exchanges as a “devastating blow.” The public program could have much more aggressively negotiated lower prices for subscribers. It could have been exactly the kind of incremental additions that can gradually lead to an improved healthcare coverage system, exapted to better serve the changing needs of American society.
The Way Forward
Despite limited success of the ACA, it created precedents for more incremental changes to build upon. The Inflation Reduction Act of 2022 extended subsidies offered to people getting insurance through the ACA online exchanges. And, for the first time in the country’s history, Medicare was mandated with negotiating some drug prices directly with pharma companies. The political resilience of the ACA is creating the space for legislation that goes beyond increasing access and takes on the cost of care as well.
Although the US may never to a traditional universal healthcare option, some more policy changes that can help us step towards similar goals are:
Reducing drug costs by reforming the notorious role of pharmacy benefit managers (an interesting treatment by
here)Expanding Medicare coverage, a monstrous challenge because of the costs involved, but one that could become more surmountable if prices are negotiated down.
Revisiting the individual mandate, which was repealed by Congress in 2017.
For a great analysis of these and other ideas, check out the thoughtful posts by
, such as this one.Obama says that the ACA was intended to be a "starter home.” Evolutionary biology shows us the choices that policymakers have next. They could allow opportunities for renovations and experimentation. Or they could throttle change, under the lobbying influence of private insurers who benefit from the status quo. But as with the dodo, not serving today’s needs risks revolutionary extinction. And at that point, rebuilding from ground-up would be the only remaining option.
It's helpful (and fun) to look at current issues through the lens of evolutionary theory! The ACA has some powerful aspects of selective fitness going for it. People won't stand for giving up things like protections for pre-existing conditions, drug price negotiations, and the other things. Conservatives talk tough about dismantling ACA, but that is politically fraught without any backup plan. They talk only of smashing, not moving forward to something better. There will be no building on ACA in the next four years. However, ACA has resilience due to enough good ideas within it. So, hopefully it won't go the way of the Dodo! But extinction has always been a part of the broader, sometimes brutal evolutionary process.
Gairik, your essay reminds me of someone explaining evolution at a dinner party, only to realize midway that everyone’s healthcare premiums have already gone up while listening.
The dodo analogy is both apt and oddly comforting? There’s something beautifully tragic about flightless birds teaching us about systemic collapse.
Keep writing essays like this. They make extinction feel less inevitable.