Public Health, Abortion and Childcare: US far behind other countries

On October 3, I wrote about the viciously restrictive Texas (anti-) abortion law, The Texas Abortion Law is contrary to women, to science, and to human values. Texas is not the only state with such restrictive laws; in my own state, Arizona, a very restrictive abortion law has been passed by the legislature and signed by Republican governor Doug Ducey that makes it a crime for a doctor to perform an abortion on a woman “just” because it has a genetic defect (including those incompatible with life, or worse, yet, compatible with a short life full of suffering). While a US district court judge has enjoined the law, Arizona’s attorney general, Mark Brnovich, has asked the judge to allow him to continue to enforce that law while his appeal is pending. That could mean, of course, felony convictions for physicians. This follows the Supreme Court, in a “shadow docket” ruling, declining to invalidate that law despite a prior US Court of Appeals ruling that did so.

These actions by Republican-controlled states are all predicated on the assumption that the Supreme Court will soon invalidate Roe v. Wade and take away any Constitutional protection for women seeking, or doctors or others providing, abortions. This may well happen with a case on the agenda for this year challenging Mississippi’s draconian law virtually outlawing abortion. That this is a distinct possibility is because of the success of the Republican party and Sen. Mitch McConnell in ensuring that The Former Guy, Donald Trump, was able to appoint 3 justices to the Court, first by preventing President Obama’s nomination of Merrick Garland (the current US Attorney General) on the specious grounds that it was the last year of his term (while there were over 9 months left), and then going ahead and then entirely hypocritically approving the nomination of Amy Coney Barrett just a week before the election, which Trump lost. Thus we have a Supreme Court with 6 Republican justices of which Chief Justice John Roberts, Jr., is the least reactionary – but no longer a swing vote. Many, including Coney Barrett (referred to by NY Times columnist Maureen Dowd in her recent piece “The Supreme Court v. Reality” (Oct 9, 2021) as “Lady Handmaid’s Tale” for her advocacy for some of the repugnant and misogynistic practices described in Margaret Atwood’s book and the later TV series, strongly opposed to abortion. It is, of course, worth remembering that large majorities of the American people favor retaining the rights in Roe v. Wade, and that in some circumstances (such as rape and incest and a threat to the life of the mother) that support is overwhelming. Not, however, on GOP legislatures or on the Supreme Court.

Much of the support that exists in the US for overturning Roe v. Wade, and in general opposition to abortion, justifies itself by claiming abortion is murder, that they are only advocates for helpless fetuses, whom they call “babies”. There are undoubtedly many in their ranks who are consistent in their opposition to killing, opposing the death penalty and war (the late Joseph Cardinal Bernardin of Chicago comes to mind, and perhaps the current Pope Francis), but the vast majority of them, including all these legislators and SCOTUS justices, are not. And, indeed, their concern for babies and children only extends back from birth to conception, not forward from birth. We got you to there, they effectively say, but then you’re on your own. Or your parents are. This country is the meanest, using the word in both its senses, unkind and stingy, of all wealthy countries in providing support for infants, children and their parents. No box of baby necessities as in Finland (available for sale in the US, but provided by the government in Finland) . No requirement for parental leave. No guarantee of health insurance coverage, not to mention adequate coverage. No support for childcare. This one is the subject of a dramatic graphic included in the NY Times demonstrating how much countries in the Organization for Economic Cooperation and Development spend per child on early childhood care. The mean is $14,436. The second-lowest, Israel, is $3,327. Hungary spends twice that, Lithuania is over $8,000 and Slovenia over $11,000. The “poor” US comes in, as in virtually all measures of caring for its people, last, at $500. Well, you know, it costs a lot to provide care for its least needy; for the billionaires who need tax cuts.

This, of course, does not bother the majority of the Supreme Court. They are not looking for consistency. They are looking for two things: 1) to enact their political agendas, and those of the Presidents who appointed them, and 2) to have people ignore #1 and lash out at people who point it out, painting themselves as victims.

Meanwhile, thing as better on the health front in the small Central American nation of Costa Rica, as described by surgeon and health care pundit Atual Gawande in the New Yorker (‘Costa Ricans Live Longer Than We Do. What’s the Secret?’, August 23, 2021). In a country with a “per-capita income is a sixth that of the United States—and its per-capita health-care costs are a fraction of ours—life expectancy there is approaching eighty-one years. In the United States, life expectancy peaked at just under seventy-nine years, in 2014, and has declined since.” This latter fact has been described in great detail in recent years, particularly in the work of Anne Case and Angus Deaton (in the Proceedings of the National Academy of Sciences, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”, and discussed by me in Rising white midlife mortality: what are the real causes and solutions?, Nov. 14, 2015). Costa Rica, in 1970, had an infant mortality rate of 7%. By 1980, it was only 2%. “In the course of the decade, maternal deaths fell by eighty per cent. Part of the change is due to improvements in access to medical care, a characteristic of middle-income countries such as Costa Rica as well as most (obviously excepting the US) upper-income countries.” This points to the second big reason, and the focus of Gawande’s article, the emphasis on public health, on the health of communities, on interventions (and spending money) on things that improve the health of all people, in great contradistinction to the US focus on providing medical care for individuals.

Public health in the US is grossly underfunded, as has been apparent since the beginning of the COVID-19 pandemic. Well, it has long been apparent to those who thought about those things. The emphasis in the US is on individual medical care, and this is what is discussed by those who have power and those who fund them, and of course the mass of journalists and pundits.This is a failure of those who should be providing accurate information, but it is also the fault of our people’s willingness to deny a problem until it is right in their face. Many Americans do not even take the preventive measures that are easily available to them (the COVID vaccine, for some reason, comes to mind) and many others are unable to avail themselves of screening and early treatment because of a lack of money or decent health insurance and so end up in extremis and grateful for whatever invasive, expensive, and often unlikely-to-be-successful medical care is available. But, as I have said before, it is less common for people to wake each morning and be thankful that they don’t have cholera because they have clean water.

It is not that the American people are stupid or have the wrong values. If a large majority support Roe v. Wade, and much larger majority believes everyone has the right to health care and that we should have a universal health insurance system. And a huge majority (about 88% including 77% of Republicans) believe that drug costs are too high, that the reason is that drug companies make too much money, and that Medicare should be able to use its clout as the nation’s biggest insurer to negotiate drug prices. Also, while we’re on it, that all children should have an excellent education, and that childcare and parental leave are truly important priorities.

But we don’t have that. We don’t have the “Finnish baby boxes”, and we don’t have universal health insurance, and we don’t have requirements that all health insurance cover everything needed, and we don’t have childcare or parental leave or excellent education for all our children or a decently supported and effective public health system or even the ability of Medicare to negotiate drug prices. Of course the poster child for opposing this latter while her constituents favor it is my senator from Arizona, Kyrsten Sinema, who has gotten a lot of money from the pharmaceutical industry. Do we think that is part of it??

The only solution is to vote them out. Make supporting public health and universal health care and affordable drugs more important to re-election than opposing abortion rights.

Blasey Ford, Kavanaugh, bias and arrogance: present in medicine, not just politics

Mostly it is pretty easy for me to think of things I want to write about in the area of medicine and social justice; there is so much awful stuff going on there. But today it was harder; I want to write about the bravery of Christine Blasey Ford, and how powerful the calm, collected testimony that she gave was, especially given the fact that she had nothing to gain except harassment for herself and her family, and even death threats that required her to go into hiding.

I want to write about the atrocious behavior of Brett Kavanaugh, who has a lot to gain -- a lifetime appointment to the Supreme Court of the United States – but chose to take the low road, not just denying the charges but displaying aggrieved entitlement, snarling and attacking and refusing to give straight answers to straight questions. Right out of the Donald Trump playbook. And absolutely not the behavior we want on the Supreme Court, or even that we heard about his control in his current Appeals Court job. Much more, in fact, like the 17-year old Kavanaugh that Dr. Blasey Ford described.

I want to write about the tone-deaf but mission-focused hubris of the 11 white men who formed the majority on the Judiciary Committee. Ten of them having made up their minds in advance, they were not going to be derailed by anything, certainly not the testimony of the witnesses. Led by their chair, Sen. Grassley, who never made eye contact with Dr. Blasey Ford but kept his eyes on the paper he was reading from, and their attack dogs (Lindsey Graham, harsh, and John Cornyn, snide) they had a woman prosecutor question the female witness so as not to look like they were who, in fact, they were. That the format never allowed Rachel Mitchell to pursue a line of questioning was irrelevant, since it was all a charade for them. It is a shame that they made old men look so dumb and evil; remember that Grassley (85) and Hatch (84) were arrogant misogynists when they were younger, and that those (like Crapo and Cruz and Sasse) still in the 40s already are the same.

But this is a blog about medicine and social justice, and while there are certainly social justice lessons to be learned (in the negative) from the disingenuous cavorting of racist, sexist, we’ll-do-this-because-we-can behavior of white men in the hearing room, it has little to do with medicine or public health. Except, of course, to the extent that this entitled behavior is so frequently seen in those fields.

I recently wrote about an example of entitled corruption in José Balsega, the former Chief Medical Officer of Memorial Sloan-Kettering Medical Center (“Baselga, graft and corruption in medical research: why should we tolerate it?”, September 16, 2018), and we just learned that their vice president in charge of corporate relations has been required to pay them back the $1.4M he made from, essentially, insider trading.

I have also written about other corrupt executives, mainly in the pharmaceutical industry (e.g., “Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?”, September 3, 2016). These “Masters of the Universe” (h/t Tom Robbins) think they deserve everything they can get, and the rest of us be damned. Thanks to women like Heather Bresch of Mylan (Epi-Pen®) and criminal mastermind Elizabeth Holmes of Theranos, they are not all men. But mostly they are, and even these women had the protection of old men; Bresch’s father is Sen. Joe Manchin (D-WV) and Holmes attracted rich old white guys like Riley Bechtel of Bechtel, George Schultz, former Secretary of State and Bechtel CEO, and William Foege, former head of the CDC and hero of the anti-smallpox crusade, in a real-life parody of a bad thriller femme fatale.

Bad behavior is rife in the medical and public health communities, motivated, like that in the pharmaceutical sector and politics, by self-interest, a desire for money and power. Aaron Carroll, in “The Upshot” in the New York Times on September 24, 2018, writes about the many forms of bias in scientific and medical publication. He takes off from an article in Psychological Medicine, “The cumulative effect of reporting and citation biases on the apparent efficacy of treatments: the case of depression”, but he points out the many forms of bias affect research and research papers in general. These include publication bias, which means journals are more likely to publish papers with positive results (our study showed this new treatment worked!) rather than negative (well, we thought this would work but it didn’t, 😞); outcome reporting bias where only the positive outcomes are published and the negatives are left out; spin where, when unable to avoid reporting results that are negative, you use language to make them seem more positive; and citation bias, whereby other authors are much more like to refer to (“cite”) papers with positive results than those with negative, thus increasing their visibility. He does not specifically discuss confirmation bias, in which researchers are much more likely to notice and report on findings that confirm their prior ideas and dismiss those that contradict them, but this is also very insidious.

Sometimes the stakes, seen by the really rich and powerful, are minor – status and reputation in the academic scientific community (recalling the old adage “competition in academics is so vicious because the stakes are so low”). However, it is not just the researchers who are at fault. Journal editors and publishers are motivated by their own metrics of success, such as the “impact factor” based upon how often articles in their journals are cited by others. And, of course, our old “friends”, the pharmaceutical companies, are behind much of this bias, suppressing negative results for the drugs they make and emphasizing secondary outcomes (unethical!). For them, the stakes are financial and very high.

Carroll does a masterful job, supported by research published in a number of journals. He ends by discussing the ways in which these practices hurt we, the people, by getting false or misleading information out to other physicians and scientists. This can lead to us receiving treatments that don’t actually work, or work as well as they are portrayed as doing, or may even be more likely to harm us than help us. He emphasizes the important fact that not all, or even most, published scientific research is not to be trusted, but that these scurrilous articles are out there, and depend upon not only reporters and the public, but doctors not reading them carefully. Sadly, many medical (and other) professionals often hear only the reports of research in the popular press or, if they read the study, read only the Summary, or the Discussion section (most easy to “spin”) instead of carefully looking at the reported Methods and Results and drawing their own conclusions. Carroll makes a series of suggestions as to how the discipline might change this culture of bias; they are good and should be pursued.

I am not sure where the blame originates, whether from our leaders like our politicians and businessmen who see truth as an option which can be disregarded in the pursuit of money and power, or our scientists who take these illegitimate roads to further their own careers, or the public which has become agnostic about truth and searches only for confirmation of their own preconceived notions (or biases). But I am sure that, at all these levels, it is a bad thing and corrosive of the progress that should come from new knowledge.

Most of us will never get the chance to publicly put ourselves out there on the line like Dr. Blasey Ford, and very likely wouldn’t if we could. We can, however, stand for the idea that truth is not “revealed” but emerges from continuing work, from confirmation by replication of studies, from more work that further elucidates the truth. And that the enemy of truth is the kinds of biases that Dr. Carroll discusses.

In talking about his suggestions for correcting them, Carroll writes “These actions might make for more boring news and more tempered enthusiasm. But they might also lead to more accurate science.” And that would be good for us all.

The Supremes and ACA: Is opposing coverage for the poor really just mean?

In the context of the historic and momentous Supreme Court decision legalizing gay marriage across the US, and its affirmation of the Fair Housing Act, the third of the “trifecta” of progressive decisions announced this week, the ruling against those who argued that the ACA forbid federal financial support of federally-sponsored rather than state-sponsored insurance exchanges, seems rather pedestrian. After all, it just decided that the intent of the ACA was to achieve what its intent was – greater insurance coverage for the American people – and this would not be invalidated by 4 poorly-chosen words in a 1,000 page bill. What is more worthy of note is that there were three Supreme Court Justices who voted against it, when it was clearly not a real issue of law but an end-run to get it invalidated on a technicality. The low point of the dissent was Justice Scalia’s juvenile characterization of the majority decision as “jiggery-pokery”, an archaic expression most recently used in the public domain in a Harry Potter movie. Of course, Scalia could make a fair Harry Potter villain; not the potent evil of Lord Voldemort, but more of a scowling, snarling Severus Snape.

But the decision has real meaning. It means that millions of Americans in the 34 states that elected to not establish state-based exchanges and thus depend upon federal ones will not lose their health insurance. That is a good thing for those people, and it is a good thing for America. It does nothing for those people who were excluded by the SCOTUS decision 3 years ago (also written by Chief Justice Roberts) that, while validating ACA, precluded requiring states to expand Medicaid. This left millions more in the states that have not done so (like mine, Kansas) without insurance.  It certainly does nothing for the millions of those without legal documentation who live here, or the many others who fall between the cracks of the law. It still leaves us without the moral, medical, social, and economic advantages that come from a truly universal health system such as any of those adopted by every other wealthy nation, which achieve better health for less cost (see graphic). But it does make us seem slightly less cruel and benighted.

Not that this will end the discussion. A small article in the New York Times of June 27, 2015 notes that “Legal challenges remain for health law”.  These include a lawsuit by House Republicans led by Speaker John Boehner maintaining ACA is invalid because it spends money not appropriated by Congress, and a series of suits by religious organizations about the law’s requirement that they cover contraception. Indeed, the whole opposition to the law has becoming akin to a religion itself; according to its opponents (obviously also including all the Republican candidates for President) it is bad as a matter of faith, even though it does so much good. Yes, it does good in costly ways, ensuring that insurance companies make their profit; it does it in arcane ways; it does it in ways which in fact cost some people more than they might have otherwise paid. But it provides several million people the opportunity to not be the Donna Atkins or Tommy Davis of the future (see Dead Man Walking: People still die from lack of health insurance, November 17, 2013).

In response to a blog in which I posted a map that shows that the vast majority of those remaining uninsured are in the states of the former Confederacy and suggested that while Southern people might not be meaner than others, the impact of their policies was (Medicaid expansion and uncovered lives: are people meaner in the South?, February 8, 2015), Bobby Cohen wrote in a comment “If meanness doesn't explain the rejection of Medicaid expansion by Southern states, what does?” Well, for many people, I suppose, it is ignorance, of the sort demonstrated by “Keep the government’s hands off my Medicare!” or what I have called the “Craig T. Nelson fallacy” (“I've been on food stamps and welfare. Anybody help me out? No. No.”!!). Or the beliefs of some of the people in southeast Kansas interviewed for Kai Wright’s excellent article “Life and Death in Brownback’s Kansas”, published in the June 22/29 issue of The Nation where it seems that “Everyone is convinced that someone else is getting a better deal, that somewhere a horde of Kansans are gaming the system and preventing the truly needy from getting help.” In a true “What’s the Matter with Kansas”[1] illustration, even the doctor at the community health clinic who is fighting hard to get care for her impoverished patients who would have otherwise had Medicaid is conflicted; Brownback, after all, is a strong anti-abortion advocate, as is she.

All of these may explain some of the position of the leaders of this movement, but a better explanation can be found in the answer to one of the questions in “Steven Pinker’s Mind Games”, a psychology quiz on the NY Times website: “the best liar is the one who believes his own lies”. But it is hard to look at, not to mention listen to or read, the hard-core right-wing justices on the Supreme Court (who, unlike the GOP’s many presidential candidates are not even running for office) without thinking that they are, essentially, mean. They are not only against helping people when it will cost them, not altruists (another Pinker question), but even when it will save them money (again, see graphic).

I do not claim to be a legal scholar of the status of any of the Supreme Court Justices, or indeed the President. I gained some understanding from “The elusive right to health care under US law”, by Prah Ruger, Ruger, and Annas in the June 25, 2015 issue of the New England Journal of Medicine, published before any of these SCOTUS decisions were announced.[2] It’s a good and readable article which helps medical people like me understand some of the logic of court decisions. One line I found of particular interest was “American constitutionalism has championed negative liberties more than positive rights.” The idea is that the Constitution says government should not be allowed to take away our individual liberties (e.g., our guns) but not so much that we have a right to things (e.g., health care).

And yet, as pointed out by Gail Collins in “Supremes hit a high note”, this Court has “…destroyed the nation’s campaign finance laws, limited workers’ rights to challenge wage discrimination and women’s rights to control their bodies. And basically disemboweled a 50-year-old Voting Rights Act that Congress had renewed by increasingly large margins on four different occasions.” These decisions, almost all of which came out differently from those of the last 2 days only by the “swing vote” of Justice Kennedy (Chief Justice Roberts did join the majority in the decision on ACA), do not always follow this logic. It is quite an extension of the idea of liberty to say that corporations are people (the founders certainly didn’t think so) or money is speech. It is quite opposite protecting individual liberty to have laws limiting the ability of women to obtain contraception or abortion (although they can sure have guns!). Whether put forward by ignorant bigots, self-serving politicians, or sanctimonious Supreme Court Justices, the concept is most consistently “people should be allowed to do whatever they want, as long as they want the same things I do, but not what I disapprove of”. Sometimes, particularly when describing the actions of the powerful, this is described as political. But I think Dr. Cohen is right; it is essentially mean.

A phrase we commonly hear is that “mean people suck”. They do, but more important, when they have positions of power, they can do a lot of damage to others.

  

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[1] Thomas Frank. “What’s the matter with Kansas?”. Henry Holt. 2004 [interestingly, published in the UK and Australia under the title “What’s the matter with America?”!] ISBN 0-8050-7339-6.

[2] Jennifer Prah Ruger, Ph.D., M.S.L., Theodore W. Ruger, J.D., and George J. Annas, J.D., M.P.H., The Elusive Right to Health Care under U.S. Law, N Engl J Med 2015; 372:2558-2563June 25, 2015DOI: 10.1056/NEJMhle1412262

ACA: Where are we? And where should we go?

I am finished writing the book, as yet untitled, that I have been working on during my sabbatical, which accounts for the sparse number of blog posts. This is not to say that the book is anywhere near ready to be published; I am sure it will need more revisions.

However, it does mean that I am likely to be posting to the blog more frequently, as I find things that inspire me to write.

Thanks for your patience!
Josh

The Affordable Care Act (ACA) has been law since 2010, and was supposed to have been fully implemented this year in 2014, although as is clear many of its provisions have not yet been. The most important has been the failure of about half our states to implement the expansion of Medicaid, which was the mechanism through which the law intended to cover all those poor (incomes under 133% of the federal poverty level) who are currently ineligible for Medicaid (most of those now receiving it are poor children and their mothers, although the majority of dollars are spent on nursing home care). This is legal as a result of the Supreme Court decision that was important because it made the rest of the law legal; this is, I think, of faint solace to those poor people who live in my state of Kansas and the others who have failed to expand Medicaid despite the fact that the federal government would have paid 100% of the cost for 4 years, then 90%.

The newest court actions that affect ACA are two Court of Appeals decisions which say, basically, opposite things about the subsidies that support the premiums of people making above 133% of poverty but less than allows them to pay the full amount.[1] One court decided that people living in states that ran their own exchanges were eligible for the subsidies, but that those who were in federally-administered exchanges were not. The other appeals court decided that both were. Of course, those states that have federally-administered exchanges are those with governors and legislatures who oppose ACA completely; they include all those who did not expand Medicaid plus many more (about 36 altogether). This suggests some political agenda; the interpretation of Congressional intent rather than parsing the words, has historically been the basis for such court decisions. It also will mean that the cases will go to the Supreme Court, sometimes known as SCOTUS, but now appropriately called COCUHL (Court of Citizens United and Hobby Lobby), where it will be amazing if a conscious, careful, legal approach supersedes politics. The decision to basically gut the Hobby Lobby decisions one remaining protection only a day after it was announced bodes ill. The Republicans in Congress have decided to sue President Obama for not implementing portions of the ACA, which, as Timothy Egan of the NY Times points out, “…they have tried to repeal more than 50 times.”[2]

What has the Republicans so flustered that they have taken to self-contradictory actions is, in fact, the success of the ACA at achieving many of its goals. These are summarized in another NY Times op-ed, by Paul Krugman, titled “Obamacare fails to fail”.[3] There has been a huge surge in enrollment, and while indeed some people are paying more (largely healthy young people who are low risk for high-cost illness, thus previously had lower premiums), most people (including 74% of Republicans) are happy with their current premiums. In addition to the early wins (preventing insurance companies from not covering those with pre-existing conditions, allowing young people to stay on their parents’ insurance until they are 26), we now add over 6 million people who are newly covered, and can access health care. Despite decisions such as Hobby Lobby, most women will now get contraceptive coverage without a copayment. It is a good thing. This is why opponents (mainly ideological) are trying any trick that they can to limit its effectiveness, including the two biggest addressed above—not expanding Medicare and trying to block subsidies for those on the federal exchanges. That is to say, trying to limit health insurance coverage to our less-affluent citizens.

But ACA, even if it came through all the court decisions unscathed, is not a solution. It doesn’t cover those who are not citizens, even though they live here. It is a gift to insurance companies, who still get to charge high rates and make enormous profits, but now have the federal government paying the premiums. Therefore, it will not really save cost. Don’t get me wrong – I am not advocating that we provide less of the health care people need to save money (although I do advocating not providing “health care” that will not help or even harm people just because someone can make money on it). I am saying that the huge profits guaranteed for insurers, and other components of our system who make profit, make it excessively costly. It costs us way more per capita, for poorer health outcomes, than do the healthcare systems of other developed countries. The latest edition of “Mirror, Mirror on the Wall”, published in 2014 by the Commonwealth Fund demonstrates this clearly; in comparing 11 wealthy countries the US ranks #11 overall, and #11 in 3 of the 5 areas examined (Efficiency, Equity), and Healthy Lives), #5 in Quality, and #9 in Access. It achieves this less-than-mediocre performance by spending (2011) $8508 per capita, while the other 10 countries spent from $3182 (New Zealand) to $5669 (Norway).[4]

The problem is not that our system is not working, but that it is. Paul Batalden is famous for saying “every system is perfectly designed to get the results that it gets”, and ours is. The results that we get are relatively poor health outcomes on a population basis, large numbers of people excluded from health care coverage (even after ACA), many people getting unnecessary care because someone can make a profit on it, and the bizarre concept that there are not only people who are preferable to provide care for (because of their wealth or insurance status) but even diseases that it is preferable to provide care for (because the profit margin is better). Our system is not designed for people’s health; it is designed so that some (providers, insurers, drug companies, etc.) can make profit. It gets the results it is designed to get.

But that is unacceptable. We need a health system designed to maximize the health of our people. All our people. And we need it yesterday.

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[1] Goodnough A, Ruling on Health Care Subsidies Puts Coverage at Risk, NY Times 7/23/14, http://www.nytimes.com/2014/07/24/us/politics/court-ruling-on-health-care-subsidies-risks-loss-of-coverage.html

[2] Egan, T, “Ambulance Chaser in the House”, NY Times, 7/26/14, http://www.nytimes.com/2014/07/26/opinion/timothy-egan-Congresss-Next-Big-Idea-Sue-Obama.html

[3][3] Krugman P, “Obamacare fails to fail”, NY Times, 7/13/14. http://www.nytimes.com/2014/07/14/opinion/paul-krugman-obamacare-fails-to-fail.html

[4] Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2014 Update, The Commonwealth Fund, June 2014. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

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”.)