Nowhere is the phrase American Exceptionalism more appropriately used than when describing our debate over health care. Outside the bubble that is the United States health care is viewed as a right, recognition that sickness and injury can strike anyone despite their best efforts and an acknowledgement of a basic obligation civilized societies have to its members.
If members of those societies were to tune in to the American debate I suspect they’d be baffled to watch grown men and women come up with ingenious ways to complicate a very simple moral issue.
From the Sublime
Consider Richard Epstein’s response to the Supreme Court’s decision to uphold most of the health reform law. Epstein, an influential law professor at the University of Chicago chided Chief Justice Roberts in the New York Times for relying on Congress’ Constitutional power to “lay and collect Taxes.” He reminds us that the Constitution restricts the use of that power solely “to pay the Debts and provide for the common Defence (sic) and general Welfare of the United States.” And he insists that extending health care to 30 million Americans does not meet this standard because “general welfare” means “benefits that must be given to all citizens, if given to any,” that is, “matters that advance the welfare of the United States as a whole.”(Italics in the original)
Extending health care to 30 million does not enhance the general welfare, argues Epstein, because it does not extend health care to all 330 million Americans.
Now consider the argument by the vast majority of the Supreme Court who voted to strike down the law’s provisions regarding states’ expanding Medicaid. Under existing law the Secretary of Health and Human Services has the right to withdraw Medicaid funding from any state that does not meet minimum standards of access and coverage. The new law gave the Secretary the authority to strip states of their existing Medicaid funding if they do not expand Medicaid. The Court struck down this provision, arguing, “the expansion accomplishes a shift in kind, not merely degree. The original program was designed to cover medical services for particular categories of vulnerable individuals. Under the Affordable Care Act, Medicaid is transformed into a program to meet the health care needs of the entire non-elderly population with income below 133 percent of the poverty level.”
To review. To Richard Epstein the entire health law is unconstitutional because it provides health insurance to too few. To John Roberts and most of the Supreme Court part of the law is unconstitutional because it provides health care to too many.
Or consider how the New York Times reported on an Oregon health study a few days after the Court’s decision. The study was noteworthy because of its laboratory-like conditions. In 2008 Oregon opened its Medicaid rolls to working age adults living in poverty. Lacking the money to cover everyone, the state established a lottery. About 17,000 people won the lottery. The randomness with which they were selected made this a perfect setting for a study comparing insured and uninsured.
The Times offered some glimpses into how the lives of those who gained access to health insurance dramatically improved.
When Wendy Parris shattered her ankle, the emergency room put it in an air cast and sent her on her way. Because she had no insurance, doctors did not operate to fix it. A mother of six, Ms. Parris hobbled around for four years, pained by the foot, becoming less mobile and gaining weight.
After winning the health insurance lottery, Ms. Parris received surgery for her foot, and additional care. She is also getting spinal surgery. Doctors have helped her address her depression, triggered by the death of one of her children. Her weight has come back down, and her mobility is far better. ‘It saved my life,’ she said.
On average, those who were added to the Medicaid rolls were 25 percent less likely to have an unpaid medical bill sent to a collection agency. Forty percent were less likely to borrow money or skip paying other bills in order to cover their medical costs.
Nevertheless the Times concludes, “For the nation, the lesson appears to be mixed.” Mixed? Why? “Expanded coverage brings large benefits to many people, but it is also more likely to increase a stretched federal government’s long-term budget responsibilities.” Katherine Baicker, a Harvard economist who worked on the study and served as an economic adviser to President George W. Bush announced, “It’s up to society to determine whether it’s worth the cost.”
What a strange calculus we who live inside the bubble use to determine whether we should care for one another.
A 2007 study by researchers at the Harvard Medical School found that 62 percent of US bankruptcies were a result of medical expenses. Equally damning, 75 percent of the people with a medically related bankruptcy had health insurance.
How does this woeful statistic compare to other countries? It doesn’t. On Frontline Washington Post veteran reporter T.R. Reid asked the President of the Swiss Federation, Pascal Couchepin, “How many people in Switzerland go bankrupt because of medical bills?” Couchepin responded, “ Nobody. It doesn’t happen. It would be a huge scandal if it happens.”
To the Ridiculous
Sometimes our uniquely American every man for himself and the devil take the hindmost attitude degenerates into caricature. Watch this exchange between Senator Debbie Stabenow (D-MI) and Senator Jon Kyl (R-AZ) during a Congressional hearing on health reform, and weep.
Stabenow, “I don’t think you can go forward and allow 60% of the insurance companies not to provide basic maternity care in a new system we’re setting that hopefully will be better than the old one.”
Kyl, “First of all, I don’t need maternity care and so requiring that to be in my insurance policy is something that I don’t need and will make the policy more expensive.”
Laugh if you will at the absurdity of Kyl’s comment, then remember that the law’s requirement that all of us pay for health insurance was a key reason the Republicans took over the House and almost the Senate, while capturing more than 15 state legislatures.
Or watch again the famous (infamous?) Republican primary debate where host Wolf Blitzer posed a hypothetical question to Congressman Ron Paul, who is also a physician. As reported in the Los Angeles Times:
“A healthy, 30-year-old young man has a good job, makes a good living, but decides: You know what? I’m not going to spend 200 or 300 dollars a month for health insurance, because I’m healthy; I don’t need it,” Blitzer said. “But you know, something terrible happens; all of a sudden, he needs it. Who’s going to pay for it, if he goes into a coma, for example? Who pays for that?
“In a society (in which) you accept welfarism and socialism, he expects the government to take care of him,” Paul replied. Blitzer asked what Paul would prefer to having government deal with the sick man.
“What he should do is whatever he wants to do, and assume responsibility for himself,” Paul said. ”My advice to him would have a major medical policy, but not before —”
“But he doesn’t have that,” Blitzer said. “He doesn’t have it and he’s — and he needs — he needs intensive care for six months. Who pays?”
“That’s what freedom is all about: taking your own risks,” Paul said, repeating the standard libertarian view as some in the audience cheered.
“But congressman, are you saying that society should just let him die,” Blitzer asked.
“Yeah,” came the shout from the audience. That affirmative was repeated at least three times.”
Health Care Outside the Bubble
A snapshot of health care outside the bubble might help put the American debate in context. This from a letter a friend who lives half the year in Paris wrote me last year:
My general practitioner in Paris answers his own telephone, or his psychiatrist wife does and passes the message. He calls after he has seen me to ask how I’m feeling. When I’m very sick he gives his cell phone no. and asks me to call him on the weekend when he is out of town and if I forget, he calls me. He comes into the waiting room himself to bring patients into his office. He sees patients out to the street door. If it’s raining and you’re sick he dials for a taxi. Himself.
A service called SOS Medecins is available at any hour of the night and a doctor will appear at the door within fifteen or twenty minutes. I have been given a cardiogram in my bed at three a.m. ($80.00) I have been given an anti nausea shot at two am. The cost of these doctors’ visits $75.00. Visiting nurses are available in every neighborhood and come to administer antibiotic shots, or change bandages, with a doctor’s prescription. The cost is about $15.00 a visit.
Billing is done by the doctor or the specialist at his desk on his computer or in longhand while you are there. His office desk and the examining table are in the same room. There is often a receptionist, never a nurse or a secretary.
The next day my friend sent me a P.S.
“Costs listed for medical care here were before any social coverage. I don’t have the ‘social’ because I’m not a citizen, have never worked here and don’t pay French taxes. With the ‘social’, payments are a fraction of that cost. When I pick up prescriptions for my friend and neighbor who is 87, I flash her card and pay them nothing.”
Inside the bubble we would describe the French health care system as socialist, a system to be condemned and avoided at all costs. Outside the United States it’s the way civilized societies morally behave.