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.