Medicine

ACA after the election: Is it is the "fiscal cliff" or the social cliff that matters to people?

I recently attended a talk by Paul Starr at the San Francisco meeting of the Association of American Medical Colleges (AAMC). Dr. Starr, a professor of sociology and public affairs at Princeton who is probably most famous for his 1984 book “The Social Transformation of American Medicine”, has recently written a new book, Remedy and Reaction: The Peculiar American Struggle over Health Care Reform. His talk was on the same topic, and was pretty good. He spoke without notes or powerpoint (lauded by many as a display of great skill, but also meaning that his “slides” are not available to those who were not present). His main technique was to divide efforts to “do” health reform – essentially to cover everyone – into a “play” of 3 acts. The first act, with several “scenes”, was comprised of efforts during the Progressive Period around WW I, the New Deal, and after WW II, to develop a National Health Insurance program. He noted that, if the play had been written by a good playwright, the scenes wouldn’t have been so similar – but they were, scuttled, at least in part at all three times, by opposition from the American Medical Association. There were other issues: in the first, the anti-German sentiment during WW I was attached to the fact that Bismarck (in 1888) had developed the first national health insurance system in Germany; in the 1930s, the Roosevelt administration chose to focus on unemployment insurance and Social Security; in the late ‘40s, Truman’s efforts were again seen as “socialist” during the early Cold War.

The second “act” comprised the passage of Medicare and Medicaid in the 1960s, and the third act the efforts for comprehensive health reform begun under President Nixon, again attempted by President Clinton, and enacted in 2010 as the ACA under President Obama. Starr spoke the day before the November 6 election, and observed that if the Republicans won and, as planned, repealed ACA, 16 million additional people who would have been covered by expanded Medicaid would not be covered. Worse, he noted, if the Romney-Ryan plan to cut Medicaid expenditures by $1.7 Trillion over ten years was put into place, another 35 to 40 million people would lose coverage. Starr was a part of the core group who developed the Clinton Plan in the early 1990s, so it is, I guess, not surprising that he continued to exhibit a preference for that plan compared to ACA. He even argued that it was really pretty simple, not something anyone who can remember those days recalls. At the time, I remember a cartoon with two panels. The first, labeled “The Democratic Plan”, showed someone at a black board covered with complex formulas and “circles and arrows”. The second, “The Republican Plan”, showed a stern man (older white man, of course) in a suit saying “Don’t get sick.” Certainly, however, the expansion of health insurance coverage under ACA, with individual mandates, Medicaid expansion (limited by state choice given the Supreme Court decision), and support for private insurance companies, is pretty complex itself.

This, however, is not why I say the talk was only “pretty good”. The fatal flaw in Starr’s analysis is that he never mentioned the 30 million people who remain uninsured under ACA (or the probably comparable number that would have been under the Clinton plan). This is inexcusable; for a supporter of health “reform” not to even acknowledge this enormous population, even by saying “well, it was the best we could get through Republican opposition”, is hard to understand. Did he forget to mention it, or did he leave it out because it might somehow weaken some of his other arguments? I obviously don’t know, but it is not uncharacteristic of many political “insiders” who get so involved in their own issues that they forget things that are of great moment to tens of millions. Perhaps it is because the best, most effective, and most cost-effective answer is a single-payer health system, and that was something he and the other Clinton health planners rejected 20 years ago off the bat, so he didn’t want to bring it up even now.

But the Obama victory on November 6, as much of a relief as it was, as much of a deep breath that we can take to know that a majority of the people were not taken in by lies, racism, and meanness of the campaign, does not end the struggle, either for the ACA or those left out of it. Yes, the election shows that America is no longer completely controlled by white men (whose votes Romney overwhelmingly won; see Maureen Dowd, Romney Is President, New York Times, November 11, 2012), but nearly half the country voted for the Republicans. This included many who were not white men, as well as most of the white men who voted for Romney despite his support for policies that would be counter to their economic self-interest. And a huge swath of states, mainly through the South, Plains, and Mountain regions, were bright red and have governors and legislatures still staunchly opposed to “Obamacare” and in opposed to Medicaid expansion in their states. And the people returned a significant Republican majority to the House, who can be expected to do everything that they can to limit the full implementation of ACA.

The Republicans opposed ACA, and opposed the individual mandate that was the necessary condition required by the health insurance companies to agree to key components of ACA such as guaranteed issue of health insurance and no exclusion of people for having pre-existing conditions. Having lost both the Supreme Court decision and the election (which means that the Court is unlikely to have its more “liberal” justices replaced by conservatives) it remains to be seen whether they will move toward support for the mandate because it benefits one of their natural constituencies (read: “contributors”), the large health insurance companies, or continue to oppose it because of their principled (read: “mean spirited and selfish”) opposition to everyone having health insurance coverage.

I fear that it will be the latter. It will not appear (at least not often; there will be gaffes) as “we don’t think everyone deserves coverage” but will be dressed in the guise of “fiscal responsibility”. “Deficit hawks” will tell us that we can’t afford it, that we will fall off the “fiscal cliff”. In his November 12, 2012 New York Times piece, Hawks and Hypocrites, Paul Krugman addresses this issue, and calls those who argue this position “deficit scolds” because their warnings and suggested policies (mostly cut taxes especially on the rich) don’t make sense. Rather, it is clear, their agenda is to decimate and eliminate Medicaid, and Medicare if they could (or at least privatize it, which will make it unable to cover seniors’ health expenses), and preferably Social Security (if they could get away with it) and any other programs that support the most, rather than the least, needy.

This is wrong (I was going to say “obviously”, but it is clearly not obvious to many). It is not only wrong on the moral count, as was succinctly presented by FDR, who said “"The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough to those who have too little"; it is wrong economically. For our nation and economy to grow, everyone needs to contribute, and to be able to do that they need to be healthy and have good access to health care. I have written about the “social determinants of health” (“Social determinants, personal responsibility and health system outcomes”, September 12, 2010), but it is really a vicious cycle, in which health and other social factors affect each other. Those social determinants, including especially poverty, that lead to poor health also lead to difficulty in getting a good education and getting a good job, thus repeating the cycle for future generations. (A good example is that of “cold winter housing”, discussed by the British Medical Association in "SocialDeterminants of Health: What Doctors Can Do” (link to pdf is on the right side of that page), and by me in “Michael Marmot, the British Medical Association, and the Social Determinants of Health”, November 1, 2011).

The right thing to do is also the economically prudent thing to do. There is a “cliff” that we should be worrying about. It is not the “fiscal cliff”, but the cliff face that so many people live too close to and are in danger of falling off.*

*(See Camara Phyllis Jones’ “cliff analogy”, “Social Determinants of Health and Equity, the Impacts of Racism on Health”.)

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