A Few Thoughts on Health Care

What we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country. – Edward M. Kennedy

In upholding the Affordable Care Act, the Supreme Court has settled for now the Constitutional authority of the President and the Congress to move the nation one step closer to universal health insurance for all. We still have a long way to go; more than 15 million people remain uncovered under the President’s health reform law and, because of the Court’s ruling, the proposed expansion of Medicaid is in some jeopardy, particularly in states like Texas and Louisiana, which seem determined to undermine the law. We still have the most expensive and least universal system of medical care in the developed world. But despite an entrenched and recalcitrant opposition, a Republican Party that has abandoned any attempt at responsible opposition and is instead interested only in the President’s defeat and which offers no reasonable alternatives to repeal, we have in place now a more just, more fair, and more universal health care system. No longer will medical care be restricted to only those who qualify for Medicare; or who are fortunate enough (like me) to work for a company or organization that provides good health benefits; or who work for the government, the military, or Congress. We are today a better, more egalitarian country.

With the Supreme Court’s affirmation, President Obama has achieved what no President before him accomplished. Starting with Theodore Roosevelt, who called for a national health system in 1912, in the past century we have witnessed Presidents repeatedly try and fail to enact some form of national health insurance. Harry Truman wrote in his memoirs that among his most “bitter disappointments as president,” what “has troubled me most, in a personal way, has been the failure to defeat the organized opposition to a national compulsory health insurance program.” John Kennedy, Lyndon Johnson (who succeeded in enacting Medicare), Richard Nixon, Jimmy Carter, and Bill Clinton each tried and failed to enact comprehensive health care reform and universal coverage for all Americans. And while Obama’s plan does not quite accomplish the broad-based, universal national health plans contemplated by Roosevelt and Truman, it is nevertheless a singular achievement in American history.

With all the focus lately on the Supreme Court and the political impact of its decision, it is easy to forget why the issue of health care is so paramount. The need for expanded access to affordable health care is a matter that directly impacts the lives, and the economic and physical survival, of millions of Americans. For those with diabetes, Crohn’s disease, severe allergies or sinus conditions, cancer, heart disease, chronic pain, or the many other illnesses and ailments that cause humans to suffer and fear for the wellbeing of their families, the ability to obtain and pay for health care is a very personal matter. No one in this country should ever be faced with the choice between economic ruin and needed medical treatment. “Death and taxes aren’t the only certain things in life,” writes Jonathan Cohn in The New Republic. “Accident, illness, and injury are too. They’ve plunged the lives of plenty of Americans, even those who thought they had good insurance, into financial and physical chaos.”

Consuming nearly one-fifth of our economic resources, the United States has the most expensive health care system in the world. We spend per capita nearly twice as much as other industrialized nations. And yet, we don’t get better results. Compared to most countries with universal health coverage, Americans have lower life expectancies, higher infant mortality rates, and lower immunization rates. It should not be this way. Canadians spend about one-half of what we do on health care and enjoy excellent medical care. According to the World Health Organization, the U.S. health care system ranks 37th in the world. American Exceptionalism? Clearly not exceptional or acceptable.

Before passage of the Affordable Care Act, 42 million Americans had no health insurance at all, and millions more were substantially underinsured. Disproportionately represented among the uninsured are the poor, the sick, and racial minorities. Many families are one illness or one layoff away from bankruptcy. The Act does not solve all of our problems, but it means that an insurance company can no longer refuse to cover someone with a pre-existing condition, or drop someone from their policy who becomes sick; and that parents can, if necessary, continue to insure their sons and daughters until the age of 26. It expands health insurance coverage to nearly 30 million people who were previously without any insurance, thus reducing the burdens and cost inefficiencies of the nation’s emergency rooms. Over the next couple of years, the Obama reforms will begin implementing new incentives for hospitals to deliver more efficient care and for more physicians to practice primary care. And it stops insurance companies from cherry-picking the people they cover.

We have been fighting over health care for most of my lifetime. Why does the United States, alone among all of the industrialized countries of the world, fail to guarantee health care to all of its citizens? Why are we so resistant to change the way we finance and administer health care in this country? Perhaps it is because we have always treated medical care as a market commodity instead of a social service. Except for those eligible under Medicare (the elderly) and Medicaid (the very poor), health care is regarded in this country as a privilege available only to those who can afford to pay for it. For the 60% of Americans that can afford it, or have been provided by their employers with comprehensive health insurance, the system works just fine. But tens of millions of others are one sick child away from homelessness. This is unacceptable in a country as rich and powerful as the United States.

I believe that basic health care is a right, not a privilege. “[Q]uality care shouldn’t depend on your financial resources, or the type of job you have, or the medical condition you face,” Ted Kennedy often reminded us during his lifelong quest for national health insurance. “Every American should be able to get the same treatment that U.S. senators are entitled to.” While most of us rely on employer provided health plans, not all employers offer benefits, and some offer less comprehensive benefits than others. When unemployment rises and employers have less need to attract workers, the health benefits they offer are often reduced or eliminated. It is the nature of a capitalist economy. As one of my law professors said to my first-year class at George Washington University in 1982, “If you are concerned about morality and the public good, Divinity School is across the street.”

The Affordable Care Act is far from perfect and only begins to address some of our most fundamental problems. I would prefer a single-payer, national health insurance system based on the many superior models that exist, including in Canada, the United Kingdom, Germany, Switzerland, Australia, and many other capitalist-based democracies. Whatever flaws exist in those systems, and none are perfect, no one has to fear bankruptcy when they are sick. All citizens have equal access to quality medical care and can freely choose their doctors. Ask anyone from Canada and Europe about the U.S. health care system, and you are likely to receive, at best, a polite stare.

How can any informed person who is not wealthy think that a system based on private insurance is better than public health care? How can we look at per capita spending on health care in the United States, the bankruptcies, the unnecessary deaths, and the comparably weak health outcomes, and possibly defend our system against those of Europe, Canada, Israel, and Australia? Americans need to open themselves to the possibility that not everything we do is always the best. As Mark Twain once said, “You can’t depend on your eyes when your imagination is out of focus.”

While markets are effective for many goods and services, they are not the proper model for preventive medicine, hospital care, and medical services. When we treat health care as a commodity distributed according to one’s ability to pay, rather than a service provided according to medical need, we wind up with insurance companies and for-profit care providers trying to avoid risky, unprofitable patients and shifting costs back to patients. We should not blame the insurance companies for this reality. Investor-owned, for-profit entities exist to make money for their shareholders and equity owners, not to provide its services to as many people as possible. As Dr. Marcia Angell, former editor of The New England Journal of Medicine, said in 2003, “We are the only nation in the world with a health care system based on dodging sick people.”

Our nation has always been too afraid and paranoid to enact a national health plan. We pride ourselves on individualism and resist community-based, government-led efforts to provide for all. The Affordable Care Act does not change these basic values. It is a private-based-insurance-company-led law that merely expands coverage to a portion of citizens previously uncovered. Politics is the art of the possible, and perhaps this was the best that could be accomplished in today’s political environment. There is simply too much money at stake, too many lobbyists representing powerful industries, too much media hype and misunderstanding to address the needs of the least powerful members of society. Someday, I hope, we will expand coverage further and enact truly universal, national health insurance, so that none of us will be at the mercy of an insurance company for our life and death needs. For now, I am grateful that we have moved one step closer to a more socially just health care system.

Turning the Page

The hardest part of raising a child is teaching them to ride bicycles. A shaky child on a bicycle for the first time needs both support and freedom. The realization that this is what the child will always need can hit hard. – Sloan Wilson

When my oldest daughter Jennifer was seven years old, I taught her how to ride a bicycle. With a large, round, bright red helmet securely placed on her small head and training wheels affixed to the rear tire, I stood behind her as she peddled up and down the driveway, and then along the sidewalk. Slowly but surely, she learned to balance, brake, and steer her bicycle. This went on for two months or so, until one day, it was time to remove the training wheels. On a bright, sunny Saturday afternoon, I stood next to her, then behind her, as she gradually gained the confidence to ride on her own. She soon developed the hang of it and peddled with authority, her small bicycle rolling along the sidewalk as she turned the corner. I ran as fast as I could to keep up with her, yelling instructions and encouragement along the way. I could sense her excitement as she experienced a taste of independence, the freedom to ride on her own, no longer in need of training wheels and a father’s protective glare.

As she proceeded further around the bend, the block commenced a slight downward tilt. Suddenly, her bike picked up speed and I soon realized she was moving too fast. “Slow down!” I shouted. “Use your brakes.” She didn’t hear me and seemed oblivious to the dangers lurking around the next corner, where a telephone pole and stop sign awaited her. I continued to run after her, but she moved further ahead, and I watched with increasing anxiety as she tried to maneuver the next street corner. Unable to gauge her need to slow down before making a turn, she braked too late and lost control. Her bike abruptly slammed into the telephone pole. Jenny flew from her bike and fell to the ground, hitting her head and badly scraping her knees on the concrete surface. I caught up to her, hugged her, and helped her to her feet, as tears streamed down her cheeks. Thankfully, she was alright, if a little beat up and emotionally scarred. It was a scary moment for both of us, one of life’s momentary setbacks, a lesson in the harsh realities of taking chances and moving to the next level.

Naturally, it was a while before young Jenny regained the courage to get back on her bike. But eventually we tried it again, this time with the benefit of experience. Jen now mastered the use of her brakes and better understood the laws of physics and centrifugal forces. She would develop into a very good, if more cautious, bike rider, and would later ride horses as well. Despite the occasional fall, she mustered the courage to jump and even compete in a few horse shows. When it was time to give younger sister Hannah bike lessons, I knew to start her on a flat surface with no inclines. When her training wheels came off, we bypassed the hilly sidewalk and took her bike to the school parking lot, thus dodging past mistakes. Such is the education of life.

“The guys who fear becoming fathers,” wrote Frank Pittman, “don't understand that fathering is not something perfect men do, but something that perfects the man.” I understood this sentiment only when I had children of my own. When my daughters were born in the early 1990’s, I became more aware of my surroundings, more sensitive to the risks and dangers lurking around each corner. My life became a little less about me and more about the little people who so much depended on me, who needed my presence, guidance, and protection.

When my kids were little, the quickest way for me to gain their attention was to sit down and look comfortable. Raising children is difficult, a grinding, time consuming process that requires sacrifices and compromises. It was not always easy trying to balance my desire to be a good father while also pursuing a career as a federal prosecutor. Trial prep sometimes took a back seat to an Indian Princess gathering or a weekend soccer tournament; whenever I accompanied one of the girls to Camp Canadensis, where sleep was at a premium and sweat and bug spray a constant companion, I dreaded the pile of work awaiting me on Monday morning. Between Saturday morning horse lessons, the commitments of travel soccer, helping with homework and papers, and providing rides to birthday parties and bat mitzvahs, raising kids and remaining involved in their lives while also pursuing a highly-charged career, with a lawyer spouse – and later as a divorced Dad – was at times difficult. And yet, there is no more important task of a parent than to raise their children to be kind, compassionate, responsible people and to prepare them for the world they will eventually confront on their own.

Among the happiest and most content moments of my life have been the days spent with my kids, taking them to ballgames, spending a week together at Disney, traveling 12 hours in the car to visit their grandparents, or just hanging out. Now that they are older and more independent, I would not change a day in the time spent with my children these past 22 years. I only wish now I could have some of those moments back.

* * * *

These past four weeks have been an emotional and exhilarating time, of milestones and awards, life accomplishments and dreams of a bright future. Now that Jen has grown up and graduated college, and Hannah high school, they are no longer in need of training wheels, less dependent upon my protective embrace. It is time to turn the page.

All the young and beautiful faces among their graduating classes reminded me of a more innocent and hopeful time, when life was full of promise and adventure, the opportunities limited only by one’s imagination and effort. “You are the best of what we were,” declared Michael Pladus, a wonderfully talented and compassionate school superintendent, at Hannah’s high school ceremony this past week. Eyeing the wide expanse of the football field, I could sense that these young men and women in their caps and gowns and smiles represent everything we once were and everything we hoped our children would become. They are younger versions of us, a reminder of our more idealistic, creative, and hopeful selves.

“It is indeed ironic,” wrote Isabel Waxman, “that we spend our school days yearning to graduate and our remaining days waxing nostalgic about our school days.” I long, as we all do, to remain forever young. But as time passes by, as my body ages, as life’s demands accumulate, the wonder years of my school days recede ever so distantly into the past. It is the memories, if not the experiences, that stay with me forever. So too, I hope, for my children. This is the gift of youth.

Graduations are important, for they allow a moment of reflection on the journeys traveled and the roads yet taken. And though I am filled with pride, I understand it is sheer luck that I was blessed with such responsible, self-assured daughters, grounded and down to earth, who possess a balanced sense of work and play, of obligations, responsibilities, and the fragility of life. They know who they are. But I sense now the realization that, for my daughters and for me, it is time to begin new chapters in the ever rapid expedition of our lives.

As I glance towards the horizon and look to the future, I pray that my girls will find their place in life. I take comfort in knowing that Jen is ready to pursue a career in graphic design; that she has developed a sense of self-confidence and knows she can compete with the best and the brightest. Before Jen went off for college, I feared she would live on macaroni and cheese and hot dogs. Now she regularly buys organic produce and experiments with exotic vegetarian and ethnic cuisines. She works hard, has really nice friends, and has matured into a wonderful young woman.

Hannah, too, is ready to find her way, to discover her passions and pursue her dreams. It seems like only yesterday when we worried if she would ever outgrow pigtails. And although her diet is still too dependent on chicken tenders, she has become an accomplished writer, a lover of animals, and an academic superstar. Through the years, I have watched Hannah and Jen develop into mature, responsible adults, independent young women ready to take on the world. I rejoice and worry at the same time.

Our children experience change and turbulence in ways never before seen in human history. When Hannah first entered high school four years ago, there was no iPad, Facebook was in its infancy, and Twitter was something only hummingbirds and nervous Chihuahuas did. Since Jen finished middle school nearly a decade ago, Google has become a verb and the internet has revolutionized the universe. The last four years have seen even more rapid advances in technology. We live now in a Digital Age. Change and anxiety are ever present.

Young people today are free to create their own future, to invent new technologies and transform the global economy. A lucky few can turn dreams into reality. But life is messy, a mixture of chaos and exuberance, misery and opportunity. Unemployment among recent college graduates is uncomfortably high. The gap between rich and poor is wider than ever, and the burdens on working families and those who do not have the benefit of inherited wealth must struggle more than in years past to survive in today’s economy.

Jen and Hannah have each completed this chapter in their lives and are turning the page to begin new ones. As their father, I want them to be financially independent, to pursue their dreams, to find a life partner who will love and respect them for who they are, and to experience a life of fulfillment and purpose. But I know they will confront a cold, competitive world with many obstacles along the way. I want always to be there for them, to protect them from harm and the pain of life. I now realize, however, that it is no longer my role. “It is one thing to show your child the way,” said Robert Brault, “and a harder thing to then stand out of it.” Whatever paths they choose, whatever rivers they cross, the only certainty is that life will have its ups and downs, excitements and disappointments. Through the successes and the stumbles, I can offer them only unconditional love, the knowledge that I will always be pulling for them, and the wise counsel of Susan B. Anthony:

Sooner or later we all discover that the important moments in life are not the advertised ones, not the birthdays, the graduations, the weddings, not the great goals achieved. The real milestones are less prepossessing. They come to the door of memory unannounced, stray dogs that amble in, sniff around a bit and simply never leave. Our lives are measured by these.

May my girls lead lives filled with passion and compassion, respect and integrity, love and laughter.