Monday, October 8, 2012

Health Care: Commodity or Right?

For more than a century, Americans have been involved in a contentious debate about health care--or rather access to it. Although the issues in this debate are often dauntingly complex, they all boil down to one simple proposition: Is health care a fundamental human right or is it a commodity? That, in turn, is a concrete application of the topic of one of my earlier posts: do you view our society and polity as a commonwealth or a marketplace? The most complete and objective discussion of the commodity versus right dichotomy is a recent book by Beatrix Hoffman, professor of history at Northern Illinois University entitled Health Care For Some: Rights and Rationing in the United States since 1930 (U. of Chicago Press, 2012.) Professor Hoffman is also the author of an earlier book entitled The Wages of Sickness: The Politics of Health Insurance in Progressive America. While I cannot hope to do justice to her carefully nuanced argument in this brief post, I will attempt to provide as faithful an overview as possible, while urging everyone to read Health Care For Some before passing judgment on the Patient Protection and Affordable Health Care Act (derisively stigmatized as "Obamacare"), or evaluating the various proposals regarding Medicare and Medicaid.

Integral to Professor Hoffman's analysis is her tight focus on the highly controversial and emotionally charged question of "rationing, or limits on health services." She wastes no time in asserting that "because the supply of doctors, hospitals, and treatments is never unlimited, medical care is rationed in every country, whether by the government, the private market, or some combination of the two." Although she essentially agrees with Dr.Arthur Kellerman, professor of emergency medicine and associate dean for health policy at Emory University School of Medicine that "we mainly ration on the ability to pay," she argues that we also ration on the basis of age, gender, employment, occupation, race, region of the country, and, above all, by access to health insurance that is provided mainly by private, for-profit companies.'The American way of rationing," she asserts, is a complex, fragmented and often contradictory blend of policies and practices, unique to the United States." As a result, we
spend almost twice as much on health care per capita, as any other modern nation, get the least "bang for our buck, and leave the most people uninsured or under-insured. The U.S. is "unique among affluent nations because it does not officially recognize a right to health care." The few rights in the U.S. health care system are those for veterans, senior citizens (only since Medicare in 1964), and the requirement to receive "stabilizing" care in emergency rooms (only since 1986), "apply only to particular groups of the population and to particular types of care."     

As Hoffman flatly states, "the argument that health care should be a right is a powerful one in a country where 'inalienable rights' are central to citizenship  and national identity." It has been acknowledged, at least implicitly, by most 20th century presidents,  including TR, FDR, HST, JFK, LBJ, Nixon, Carter, Clinton, and Obama. (Yes, at least on this issue,"Tricky Dick" comes off sounding like a cross between "Honest Abe" and FDR, compared to Romney, Ryan, and their cohort who have stolen the Republican Party.) Over the years, demands for health care as a right have been asserted by organized movements of workers, the elderly, African Americans, and others, as well as by legions of intellectuals and social activists. According to Hoffman, "rights consciousness" has been also been implicit "when unemployed people crowded into free clinics, or senior citizens wrote to Congress that they could not get health insurance, or parents sued a hospital after their dying child was turned away from the emergency room" Public opinion polls over the last several decades have clearly expressed agreement with the statement that access to health care is, or at least ought to be, a fundamental right. Although advocates of "American Exceptionalism" disdain the experience and opinion of other nations, the World Health Organization proclaimed "the highest attainable standard of health is one of the fundamental rights of every human being" as early as 1946, and the United Nations included the right to medical care in its Universal Declaration of Human Rights in 1948. But what red-blooded American cares what those "socialist" organizations think? (They used to be considered "communist" during the Cold War, but times, and epithets, change.)    

Rights consciousness, according to Hoffman "conflicts with another pervasive notion: that health care is a product like any other, and that private competition and the profit motive should be important components of the US health system." Without that, they argue, medical innovation and quality would soon come to a halt. (Of course, they conveniently ignore the fact that perhaps the lion's share of advances in medicine have come from the NIH, the VA, non-profit foundations, and universities.) Who are these proponents of the marketplace model? Some of them are "true believers", but the majority are for-profit health insurance, pharmaceutical, and medical devise manufacturers and their investors, hospital conglomerates, and those physicians whose primary concern is maintaining their luxurious incomes. (U.S. physicians are far and away the most highly paid professionals and earn substantially more than their counterparts in other affluent countries.) On the other hand, two of my sons are M.D.s and I know that there are at least as many physicians for whom the Hippocratic Oath is a much greater incentive than making as much money as possibl). Indeed, physicians have been sharply divided over universal health care for the past century and a half--and still are.) "Private power in the US health system," Hoffman charges, "has been built and maintained with the support of tax dollars, contributing to the limitation of universal rights,, the persistence of unjust and inefficient rationing, and very high costs."

To get a better sense of the ongoing conflict between medical care as a "commodity" versus a "right", it is helpful to examine five different historical periods: the Progressive Era, the 1930s, the immediate post World War II period, the 1960s, the early 1990s, and the current battle over "Obamacare."  The contest during the Progressive Era is cogently chronicled by Ronald. L. Numbers, professor of history of medicine at U.W.-Madison in Almost Persuaded: American Physicians And Compulsory Health Insurance, 1912-1920 (Johns Hopkins U. Press, 1978). The debate over health insurance began in the late 19th century, due to the confluence of several developments:the tremendous advances in medical science, the growing gap between those who were able to afford medical care and those who could not, and the adoption of some form of compulsory health insurance in Germany (1883), Austria (1888), Hungary (1891), Luxembourg (1901), Norway (1909), Serbia (1910), Great Britain (1911), Russia (1912), Roumania (1912, and the Netherlands (1913). The major credit for raising the issue of health insurance in the U.S. belongs to the American Association for Labor Legislation (AALL), " reform minded social scientists eager to translate the principles of social justice into concrete legislation." Their cause was taken up in 1912 by Theodore Roosevelt and the fledgling Progressive Party, whose platform advocated "the protection of home life against the hazards of sickness, irregular employment, and old age through the adoption of social insurance adapted to American use." Although the Progressive Party failed to elect TR president, its contingent of settlement house residents, academics, and social and political activists continued to agitate for the party's social and economic justice platform, while the AALL formed a Committee on Social Insurance to "study conditions impartially, to investigate the operation of existing systems of insurance, to prepare carefully for needed legislation, and to stimulate intelligent discussion." One of its key members was Isaac M. Rubinov, a professed socialist and physician, who served a bridge between the committee and the American Medical Association (AMA). Although weak and deeply divided, the AMA House of Delegates demonstrated considerable support for medical insurance in early 1916. By 1920, though, World War I and the Red Scare caused the AMA to condemn "socialized medicine" to what Numbers calls "death by hysteria." Even so, he concludes, "nothing seems to have played a greater role in molding opinion than money." Much of the early positive enthusiasm of the AMA was due to the belief that British doctors benefited greatly for National Health Care, and when it became apparent that American physicians were actually beginning to out-earn their colleagues across the Atlantic, support quickly disintegrated.

Needless to say, the ephemeral prosperity and reactionary politics of the 1920s swelled the opposition of physicians, politicians, and the affluent public to "socialized medicine." The onset of the Great Depression, however, exacerbated what Beatrix Hoffman documents as "a crisis of access."  Despite an escalating groundswell of pressure from unemployed councils, rapidly organizing labor, Congressional liberals, civil rights organizations, academics, policy wonks, social workers and the like, universal health care was not incorporated into what became the Social Security Acts of 1935.  The act included old age and disability coverage, unemployment (and later workmen's) compensation, and Aid to Families with Dependent Children (AFDC). (This last was "welfare as we knew it," before it was trashed by Reagan's deceitful and callous rant against "welfare queens" and finally gutted by a coalition of Republicans and centrist/conservative Democrats during the 1990s.) FDR initially backed some form of universal health care, but eventually reneged because he regarded the other provisions of the SSA more pressing, and because he was unwilling to jeopardize his entire program by adding the AMA to the growing list of "economic royalists" calling for his defeat in the 1936 election. After his landslide victory, he called a National Health Conference composed of friends and foes alike, to discuss the issue, but he refused to back Senator Robert F. Wagner's bill to provide matching funds matching funds for states willing to institute their own health care programs.FDR later included health care among the principles of the Atlantic Charter and the Economic Bill of Rights, but concrete proposals were placed on the back burner for the duration of World War II. Two of the rights contained in the latter statement were "the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment" and "the right to adequate medical care and the opportunity to achieve and enjoy good health." In addition, ad hoc medical insurance programs were established for soldiers, veterans, and even workers in some industries crucial to the war effort.     

For its part, the AMA took refuge in the "physician's right to compensation" and the imperative to keep government from interfering with the doctor-patient relationship. The editor of the JAMA even went so far as to deny the need for health insurance because Americans were "essentially a healthful people." To combat the drive for national health insurance, the AMA proposed building more hospitals under the complete control of medical professionals (even though it had no problem with federal subsidies for building them), and the establishment of Blue Cross and Blue Shield as the purveyors of their own unique form of private, prepaid insurance. BC and BS were controlled by the very providers whose services they covered and, according to Hoffman, "their creation was both a response the national discussion on health rights , and a way to forestall future reform efforts." This combination of professionally administered hospitals and BC/BS has remained the core of the AMA's position down to the present day and "became an effective argument for voluntary, private solutions to the nation's health  care crisis." The AMA also opened its first Washington lobbying office in 1943.(While it is easy to stigmatize the AMA's position as brutally self-interested and morally obtuse, I must admit that I remain fully committed to the tenure and shared governance systems "sacrosanct" " to my own profession.)

The momentum from the New Deal and World War II also emboldened President Truman to make his own drive for universal health care. In September, 1945, he set forth his "Fair Deal" platform, which included a call for national health insurance. Unlike FDR, HST was firmly committed to the idea because of his own experiences and observations. Two months later, he went before Congress to urge it to enact universal health care, along with accelerated hospital construction, public health expansion, and federal funding for medical training and research. He supported a reintroduction of the Wagner-Murray-Dingell Bill which had been defeated before in 1938 and 1943. Congress passed the Hill-Burton hospital construction Act, but rejected the other proposals. Public opinion polls--still in their infancy--showed that 75% of the public supported the idea. Truman touted universal health insurance at every stop in his famous "whistle stop" campaign of 1948. After his reelection, he went before Congress again in April 1949, contending that passage "will mean that proper medical care will be economically accessible to everyone covered by it, in the country as well as in the city , as a right and not as a medical dole."    But his proposal met with staunch opposition from Congressional Republicans and Southern Democrats who feared the program would force racial integration on the South. Under siege because of his platform on civil rights and charges of communist infiltration in his administration, Truman turned advocacy of health insurance over to the non-governmental Committee for the Nation's Health, which included such luminaries as Eleanor Roosevelt and William Green, president of the American Federation of Labor. But the opposition was "more ruthless, well-funded, and organized."

Headed by the AMA, it launched "a blitz against the national health proposal that was unprecedented in the history of lobbying." Typical was a supposed letter from "A Laborer" to the Chicago Tribune,( whose abiding  concern for the working class was beyond question), in which he denounced the payroll tax levied to finance the program as one people will have to pay "regardless of your probability of sickness, regardless of the size of your family, ,and you'll pay from now on."  He rejoiced that he was "still a free man, can choose my doctor, and can carry insurance if I like when I need it most." Under such a barrage of misinformation and outright lies, public support for health insurance dropped from 75% in 1945 to only 21% by 1949. When Truman left office in 1953, all hope for universal health insurance apparently disappeared, while the number of private, for-profit companies proliferated exponentially, and the provision of health insurance through them became a widely expected "fringe benefit" for employees of most major corporations.

In 1961, however, President John F. Kennedy announced his support for a medical care addition to Social Security and enlisted the support of organized labor, retired people, and civil rights groups. The AFL-CIO formed the National Conference of Senior Citizens (NCSC), which launched a massive letter-writing and postcard campaign to members of Congress, and sent mass mailings to senior citizens.In May, 1962, JFK addressed a mass meeting in Madison Square Garden organized by NCSC in which he challenged the idea that such a program constituted "socialized medicine" or a threat to the medical profession's integrity. The speech touched off similar rallies all over the country. "Such a noisy display of support for national health reform," Hoffman insists, "was unprecedented." But the AMA launched "Operation Coffee Cup," a nationwide blitz that included that included "coffee klatches" hosted by doctor's wives, placing attack literature in physician's waiting rooms, and a  recorded speech by Ronald Reagan that was widely circulated. Leading the reaction to the AMA onslaught were Martin Luther King, Jr. and Walter Reuther of the United Auto Workers (UAW), who proclaimed of Operation Coffee Cup that "if they put it in bags , it would help your lawn grow better." Ironically, Medicare benefited from the sympathetic reaction to JFK's assassination and the atmosphere of reform that also produced The Civil Rights Act of 1964, the Voting Rights Act of 1965, and the Immigration and Naturalization Act of the same year. Both beneficiary and generator of that environment, President Lyndon B. Johnson won a landslide reelection that all but guaranteed the passage  of Medicare and Medicaid. Stressing the measure's link to both FDR and HST, LBJ flew to Independence, Missouri to sign the bill with Truman at his side. But the reformist euphoria of the early 1960s was soon destroyed by the Vietnam War and the vehemence  of the backlash against the Civil Rights, Anti-War, and Feminist movements. The split in the Democratic Party ultimately led to LBJ's decision not to seek another term and the election of Richard Nixon in 1968. Surprisingly, he proclaimed that there was a "massive crisis" in health care and that inaugurating a national health plan was the "highest priority" of his administration." What emerged, however, according to Hoffman, were two developments that would "reaffirm rationing at the expense of rights" The first was the "employer mandate" that would require most businesses to provide health insurance as a "fringe benefit." The second was the proliferation of Health Maintenance Organizations (HMOs), a form of prepaid group practice insurance. For better or worse, these two concepts have pretty much remained the backbone of our health care system down to the present day. The former even became a pillar of the health care plan proposed by the administration of Bill and Hillary Clinton.                                    

For most people under 50, the battle over health care dates from the early 1990s.The issue was given great impetus in 1991 by Harris Wofford's upset victory for the U.S. Senate in Pennsylvania, in which he proclaimed that "there is nothing more fundamental than he right to see a doctor when you're sick."  When Bill Clinton accepted the Democratic nomination for president in 1992, he proclaimed  a vision of America "where health care is a right, not a privilege." As a centrist "New Democrat", he promised universal coverage through a system that would contain costs while preserving the private, for-profit marketplace. The percentage of Americans covered by private health insurance peaked in 1982. A decade later, 37.1 million of Americans were not covered by health insurance, up from 29 million in 1979. The combined pressure of rising costs and business downturns had motivated many companies to contravene the "employee mandate;" 84% of the uninsured were workers or their dependents,  the vanguard of "the working poor." The task of drafting the proposed legislation was delegated to a Health Care Task Force, consisting of more than 600 "experts," chaired by Hillary Rodham Clinton, even though she held no official government office. The details of their 1,440 page proposal are far too complex to discuss here (even if I understood most of them.) Suffice it to say, it included a complex system of "managed competition," with myriad private insurers organized into regional health alliances overseen by a National Health Board. It retained the employer mandate, with subsidies for smaller employers and the unemployed.

Although public opinion was initially favorable to the Clinton plan, it soon began to turn. The Health Leadership Council, an ersatz organization founded by the CEOs of fifty major health insurance companies drug and medical devise manufacturers, and hospitals, began to run ads around the country charging that the plan would lead to health care "rationing" and bureaucratic interference with patient's rights to choose. It created what Hoffman has judged "the most famous anti-health care ad campaign of all time." The spots featured a hypothetical
middle-aged, middle-class suburban couple named Harry and Louise, sitting at their kitchen table, ruminating on how the Clinton plan would adversely affect their doctor-patient relationship. They bemoaned that the change would bring "you know, long waits for health care and some services not even available." They stigmatized the plan as a sinister European-Canadian conspiracy that would take away the coverage they currently enjoyed, "Rationing" and "government takeover" quickly became the operative scare words. Compounding the problem, Clinton did not have a popular mandate like FDR or LBJ, and no strategy for mobilizing public opinion. Moreover, the process by which the plan was produced smacked of secrecy and the elitism of "experts,." while the system itself was far too complicated. Health alliances, managed competition, and National Health Board "not only failed to capture the public's imagination, but also made it much easier for opponents to attack the plan." By the fall of 1994, Congress pronounced the Clinton initiative as dead before arrival . Efforts to enact a Patient Bill of Rights never even got that far.

"W" took office in 2001(with the connivance of the Supreme Court) pledging to keep the federal government out of health care. He insisted that adequate medical care was available to everyone through hospital emergency rooms that were legally bound not to turn truly sick or injured away, and sought to shift the cost of health care to consumers through higher deductibles on private insurance plans. He blatantly attempted to deregulate private insurance and drug companies, while redirecting federal Medicare and Medicaid payments to them. "W" had promised to provide prescription drug coverage for Medicare recipients, while surreptitiously plotting to give private insurance and drug companies access to them. The result was Medicare,Part D with its notorious   "donut hole," and the proliferation of "Medicare Plus" plans. In actuality, as Hoffman asserts, "D" expanded benefits, while shrinking access to those who could survive their hiatus in the donut hole.The Bush administration also
created Health Savings Accounts (HSAS) that allowed consumers to save up to $2,000 a year in a tax-free savings account to be used solely for health costs. This would enable those would could afford to put the money aside to purchase or accept an employer's offer of private health insurance with a high deductible. Like all Republican proposals,HSAS amounted to substantial windfall for insurers and a transfer of costs to consumers, Not only would insurers save the costs normally incurred by having lower deductibles, but they could raise deductibles on every policy holder, even those who could not afford to set aside $2,000 a year. It was like milking the cow at both ends.

All of which brings us to the brouhaha over "Obamacare,"a maze in which I would most likely be unable to find my way. My best advice is to recommend the cogent summary and analysis by Hoffman on pp. 188-221. The best that I manage at this point is to present my own synopsis of the history of health care. To begin with, I have tried to demonstrate that the issue is more than a century old, but that we are now no closer to "health care for all" than we were in TR's day. In my more pessimistic moments, I doubt that we will ever achieve anything like it, given the wealth and power of the opposition, and their ability to convince lots of people who would benefit that it is "un-American" and "socialistic."  As with most things, I can understand the naked self-interest of its opponents, but not how they can convince large numbers of people to vote against their own self-interest. While I firmly believe that access to health care is a basic human right, and an absolute necessity in modern society, I would be happy if society would at least realize that it is a need, as opposed to a want.  The whole thrust of our consumerist culture is to turn wants into needs, but in the case of health care the powers that be have succeeded in reversing the formula: turning a basic human need into a want that should be allocated by market forces alone. It is far less conscience-troubling to deny people entre to a want than to an absolute need.

Moreover, the American belief in "exceptionalism" predisposes a lot of citizens to reject anything that smacks of being "European," "foreign," or, worst of all, "Canadian."  The modern world is filled with dozens of universal health care systems that are "better" than ours by any objective,quantitative measure. The "bottom line," so sacrosanct to our psuedo-capitalistic culture, is that the U.S. spends way more per capita on health care  than any other affluent nation, and that it accounts for a far greater slice of our GNP, but that we rank 38th in life expectancy, 34th in prevention of infant mortality, and 37th in overall quality.I have always believed that our present system is unconscionable, probably even immoral by my lights. How can we justify making a profit out of "right to life"? But the plain hard facts make it clear that it is also economically destructive. Those politicians who keep insisting that the U.S. has the finest health care system in the world, have to know that, to paraphrase James Carville in 1992: Its ACESS, stupid.



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