Today, after more than a year of proposals, negotiations, setbacks, forward progress, and rancor, the U. S. Congress will finally vote on the largest-ever effort to overhaul the U.S. health-care system. Health-care reform, it’s popularly called, and it’s a vote that is being hailed by media pundits and President Obama alike as an historic moment, a moment that the U.S. has been working toward since the first efforts at health-care reform took place nearly a century ago. At the moment, it looks like Democrats have garnered the 216 votes needed for health-care reform legislation to pass. The White House has struck a deal with anti-abortion Rep. Bart Stupak (D-MI), who had introduced draconian anti-abortion language into the bill; under the deal, President Obama will issue an executive order that clarifies that federal funding will not be used for abortions (I’ve got lots to say about that part of the deal — but that’s not the topic of this post). Republicans, of course, are holding out just so they can say they did. Wonder what that will look like 50 years from now in the history e-books my 2-year-old will be nostalgically downloading.
News media are feeding the furor. The Washington Post called the debate over abortion language in the bill a “cliffhanger,“ The New York Times proclaimed “Health Vote Caps a Journey Back from the Brink,” National Public Radio blogger Mark Memmott declared the debate at its end in a post titled “Health Care: The Final Chapter.” Yes, it is historic, yes, today’s vote will dramatically alter the way health-care is paid for and delivered in the United States; and yes, it is the “final chapter” of a ridiculously partisan debate that’s been informed more by politics than health data. The bill does represent the largest revision of the U.S. health-care system since the introduction of Medicare in the 1960’s (which, by the way, was overwhelmingly unpopular).
But the historic moment is not one vote, one declaration that the bill has passed (or not), but in a series of hundreds of thousands of historic moments as individuals, companies, health-care providers, and every other stakeholder in this game begins to live out the policies enacted with this bill. Changes in health-care systems doesn’t happen in legislative halls. True change will happen once the hundreds of reforms in the bill begin to be implemented — that’s the only way we will find out what is working and what isn’t. The policy wonks at the George Washington University School of Public Health and Health Services National Health Reform Law and Policy Project say it well on their website:
“Change will come over time. The legislative proposals themselves can be thought of as the critical opening act, broadly directive in structure. Many of the most important details will be addressed through the implementation process, as federal and state agencies begin the enormous task of implementing reform, and as consumers, patients, employers, medical and health professionals, health insurers, and the health care industry begin to embrace change.”
The health-care reform bill will change the system in multiple ways that few people are talking about. For instance, government agencies such as local public agencies now employ full crews of people who spend their time determining whether people are poor enough to qualify for entitlement programs such as Medicaid or state and county medical indigent funds. What’s going to happen to those jobs? Will they be reframed, lost, changed in fundamental ways? The people working in those jobs act as gatekeepers — the language they use is even pejorative: Those who “qualify” are, to borrow a phrase from Michael Katz, the “deserving poor.” Those deserving poor are often pregnant women, children, the disabled, and others who we have been taught to feel justified in helping. But the new legislation will open up Medicaid to single, low-income people who don’t happen to be pregnant or severely disabled. Who knows? The homeless guy standing in the ditch over there might even be eligible for coverage. He could visit a primary care clinic instead of calling an ambulance.
What will happen if we no longer need those gatekeepers to discern between the “deserving” and “undeserving” poor? As President Obama told a crowd at a George Mason University in Northern Virginia last Friday, it’s really about much more than who pays for health-care. It’s about our beliefs about health care — and the right to receive it. Quoting partly from a posthumous letter penned by the late Senator Ted Kennedy, Obama told listeners:
“It’s a debate that’s raged not just for the past year but for the past century. It’s a debate that’s not only about the cost of health care, not just about what we’re doing about folks who aren’t getting a fair shake from their insurance companies. It’s a debate about the character of our country; about whether we can still meet the challenges of our time; whether we still have the guts and the courage to give every citizen, not just some, the chance to reach their dreams.”
But no matter what the outcome of the vote, no matter what changes health-care reform brings to our health-care system, our belief system won’t change overnight. No living person in the United States has known (at least within U.S. borders) what it would be like to live in a world in which health-care is considered a right, not a privilege (to invoke the old yet meaningful cliché). Even Mexico, our resource-poor neighbor to the south, offers its residents a constitutional right to health care. Can they deliver that consistently? No way. But it’s a belief that provides the foundation for building a health-care framework.
In contrast, all of us born and raised in the United States have lived in world in which health care is a precious commodity, health insurance coverage is linked strongly to a Puritan work ethic, and medical costs are the big “what if?” And a sweeping overhaul of health policies is not going to change that belief system. A consistent refrain among opponents of health-care reform is that “we” should not pay for health insurance coverage for the 32 million Americans who are uninsured. They forget that “we” includes those 32 million people, the vast majority of whom work in low-wage jobs for small employers who cannot or will not provide coverage to their employees. And “we” are already paying — in many, many ways.
Here’s one fictitious but all-too-common example: Isabel, a 45-year old Hispanic woman, has worked for a small retailer in Rural Hometown, USA for 10 years. Her employer is herself under-insured, with a policy that carries a $5000 deductible. She can’t afford to pay health insurance premiums for Isabel, her only employee. Isabel is divorced, so the $18,000 she makes every year making and selling soaps and lotions is too much for her to qualify health insurance entitlement programs. Divorced, she raised her two kids on Medicaid, but the youngest lost his coverage last month when he turned 18.
Last week, Isabel suddenly collapsed while she was at work. An ambulance transported her to the local hospital, where she was seen in the emergency room and diagnosed with diabetes. She hasn’t gotten the bill yet, but she knows she won’t be able to pay it except for a little at a time — it’s likely to be at least six months’ wages for her. But Isabel’s medical expenses have only begun. She can’t afford the medications, the test strips (about a dollar apiece), and the regular doctor’s visits that she needs to control her diabetes.
Who’s paying for Isabel’s medical expenses as she writes her monthly $50 check to the local hospital and ambulance service? “We” are — in multiple ways. Without access to the tools she needs to control her blood sugar levels, chances are she’ll become a “frequent flyer,” well known to local ambulance crews and emergency room staff. She’s likely to have repeat diabetic crises, and more likely to develop complications of the disease — including heart and blood vessel disease, eye disease, slow wound healing that can lead to amputations, kidney disease… the list goes on. She may not be able to work but may soon move to that “deserving poor” category of the disabled. Under the old system, only then will she qualify for Medcaid so that “we” pay her now-hefty medical fees — much of which could have been avoided with visits to a primary care doctor, prevention measures, and the tools to better control her blood sugar.
Under health-care reform, Isabel — and the other 31,999,999 Americans without health-care coverage — will have a chance to manage her disease, if not prevent it in the first place. She can access the relatively inexpensive primary care and prevention resources she needs. We all pay much, much less, not only in dollars, but in retaining her as an active, productive member of society. But first, we have to believe it. We have to believe that access to health care is something we deserve, not earn. And then, only then, office visit by office visit, patient bill by patient bill, will we truly reform health care.