Ken’s Take on the World


Healthcare: Privilege or Right?

As Republicans struggle to obtain enough votes in the US Senate to pass their version of a bill (Better Care Reconciliation Act) that was originally brought forward to repeal, and replace, the Affordable Care Act (ACA) much focus has been placed upon the economic costs and the personal costs to those who would be affected should this legislation become enacted into law.  As one who has paid attention to the debate over healthcare access for the past three decades, I have been thinking of a much deeper question that we should be asking of ourselves as it would, perhaps, better drive the debate over this legislation.  The question that each of us should ask is this:  Should healthcare be considered a privilege, a commodity, that should be available only to those who can afford such care or, should it be considered a necessary right for every person that must be protected, and assured by government?

 

When I have posed this question to those who express opposition to the ACA, the most common response that I receive is that healthcare should be treated as any other service that a person would seek out.  The most common support offered for this position is that every person receiving services should be required to pay for such services.  To bolster this claim, these critics argue that it is not fair to expect others to pay for services that they receive.  On its face this appears to be a reasonable argument that must be considered.  After all, you wouldn’t take your car to a mechanic and not be expected to pay for repairs or maintenance on your vehicle.  You don’t take your family to a restaurant and expect to receive free food, do you?  You wouldn’t call an air conditioning repair person and expect to not receive a bill for the parts and services provided, would you?  These criticisms appear to suggest that healthcare services and products are no different than whether or not your vehicle or your heating and cooling systems at home are functional.  This is a false and illogical argument.

 

When one dines out at a restaurant, one knows what they can afford and if they are unable to afford to dine at a certain establishment they simply eat dinner at home or at a less expensive restaurant.  When your air conditioner is on the fritz, if you do not have the money available for repairs, you will need to open your windows, use fans, or other methods of staying cool.  For those with underlying health conditions in which extreme heat is dangerous, communities provide cooling centers, or family and friends are often able to step in to provide temporary shelter until the air conditioning is repaired.  Even if a new central air system must be installed, the cost is almost always going to be less than $5,000 USD.  Many heating and cooling companies will also finance this amount to keep costs manageable.  Similarly, if you need repairs on your automobile, you can determine what are the most crucial and pay for those and defer other repairs until later.  Or, your community may have decent public transportation available.  Or, you may be able to car-pool to work or use a ride-sharing service.

 

Healthcare, unlike these other services, is not a commodity that can simply be delayed in many cases.  I have frequently likened the provision of healthcare as an essential service that must be available to every single person.  Similar to a community that provides fire departments and trained personnel to operate this life-saving equipment.  Or, law enforcement agencies that respond to safety or criminal complaints.  Or, military agencies like the Coast Guard who respond to emergencies on our nation’s waterways.  We don’t bat an eye when we are asked to fund these critical services.  As a society, we have come to realize these are critical pieces of infrastructure that exist for the benefit of each of us even if we never need to directly use these services.  Why, then, do we look at healthcare differently?

When I have attempted to discern how so-called conservatives continue to maintain the position that healthcare is a commodity, and not a right, in addition to the arguments about paying for services and the burdens of having to pay for those who cannot afford these services, they remind me that healthcare services are already provided to people in the nation’s Emergency Departments (ED) regardless of one’s ability to pay for such care.  This, then, implies there is, in fact, some existential right to healthcare.  When I point out this inconsistency in logic, one person actually mentioned that fewer (uninsured) people seek medical care as if this implies lower costs to taxpayers.  The problem with this (il)logic is that while uninsured individuals are far less likely to present to a primary care physician in the community setting, they are far more likely to present to an ED for treatment of conditions that can be much more effectively, and economically, managed in a community setting by a primary care physician.  This translates into significantly increased healthcare costs for all of us.  The average cost of an ED visit in the United States is nearly $2,200 based on a study described in “The Atlantic.”  Compare this to the average cost to a primary care provider (PCP) in the US which is only $100 based on an Agency for Healthcare Research and Quality (ARHQ) study by the Department of Health and Human Services (HHS).

 

A review of multiple studies has demonstrated that access to health insurance is correlated with significantly improved health outcomes.  The review, published recently in the “New England Journal of Medicine” (NEJM), documents that improved healthcare outcomes are especially notable among pediatric patients.  Further, this review notes that not only are healthcare outcomes improved, but other measures of quality of life, including educational achievement, are improved with access to health insurance.  Other studies have demonstrated the significant economic consequences associated with illness.  I am not only speaking of the direct costs associated with providing medically-necessary care, but the impacts that illness and preventable injury have on individual and societal economic stability and growth.

 

I believe we must frame the debate over access to health insurance as one of a necessary right that must be protected by government actions.  Only then, will we be able to determine the most effective means of financing healthcare in the United States.



Healthcare: Commodity or Essential Right

The recently, spectacularly, failed American Healthcare Act (AHCA), once again, brought to the forefront the debate on whether healthcare access should be considered a commodity, much like an automobile, subject to the whims of a free market and made available to those who can afford it or, rather, that healthcare is an essential right of all Americans that must be guaranteed by government.  Democrats appear united behind the concept that healthcare access is crucial to society and must be available to every US citizen regardless of their economic status.  As the debate over the AHCA progressed, it became obvious that Republicans are divided over this central question.  Polling shows that overwhelming majorities of Americans believe every citizen should have access to high-quality, affordable, healthcare.  In this, it appears the GOP is at odds with the majority of Americans.

 

This week, President Trump signaled the AHCA is not actually dead and that his campaign pledge to repeal and replace the Patient Protection and Affordable Care Act, also known simply as the Affordable Care Act (ACA) or, “Obamacare” continues onward.  The problem with this position is that the President has not articulated what this would look like.  Even with Republican majorities in both chambers of Congress, and without input from Democrats, a coherent plan that would meet the President’s promises of providing affordable health insurance to even more Americans, and at lower costs than the ACA, was not presented.  Competing factions within the Republican Congress ensured that no bill put forth would garner a majority of votes or even entice moderate Democrats to join in support.  Party leadership attempted to rush the bill through the House even prior to scoring by the nonpartisan Congressional Budget Office (CBO) which ultimately decided that, although ten-year cost projections would reduce the budget, the result would be more people without health insurance than prior to enactment of the ACA.

 

After the AHCA was pulled prior to a vote, the President commented, “Who would have known that healthcare would be so complicated?”  What?!?!  Besides anyone who has ever studied this topic?  This point underlies a central problem within the Trump Administration.  There is a serious lack of competent Administration leadership that might be able to shepherd complicated proposals through a Congress that is itself lacking in effective leadership that is committed to promoting and implementing legislation that will serve to actually benefit the American people.  Basically, Republicans have demonstrated that, since at least 2010, they lack the ability, or desire, to govern in the best interests of the people.

 

The failure of the AHCA effectively leaves the Republican leadership in Congress with two choices.  They can continue in their efforts to undermine the ACA which will lead to its eventual collapse, or, they can work with Democrats to strengthen the law which is what a majority of Americans currently favor.  It should be noted that the ACA has been effective and would continue to remain viable for at least the next decade but for efforts of the Republican Party over the past seven years.  Elected Republicans, and right-wing talking heads on radio and television, have spent the last seven years misleading the American public.  This has resulted in ballot box gains, however, it has not actually helped the American people.  While the ACA did not seriously further the debate on whether healthcare was an essential right versus a commodity available to the highest bidder, it did suggest that access to insurance to provide for healthcare expenses was a necessary thing that should be promoted by government.  In contrast, the debate among Republicans since 2009 has brought into the open the role of government in healthcare access at all levels.  It should be noted that prior to 2010, there was no question that government should ensure the availability of some access to healthcare for all Americans.  In 1986, President Ronald Reagan signed the bipartisan Emergency Medical Treatment and Active Labor Act (EMTALA) into law.  Likewise, COBRA was enacted under the Reagan Administration which provided individuals with a continuity of health insurance coverage.

 

The most recent debate between Republicans over the AHCA has placed a focus on whether government has any role in determining access to health insurance or healthcare itself.  This debate also served to highlight a disconnect between elected Republicans in Congress and their constituents.  Had the AHCA passed, the harms would have been felt significantly more among rural voters who overwhelmingly voted Republican over the past several election cycles.  The more extreme members of the GOP who make-up the Libertarian-wing (aka the Freedom Caucus formerly known as the Tea Party caucus) believe healthcare should be left to the winds of a completely free market.  Health insurers should be let alone to serve only the customers they desire and to charge whatever rates the free market might bear.  Let the buyer beware lest they procure a policy only to find out it lacks the protections necessary when they are needed, or worse, they are dis-enrolled when they become ill or seriously injured.  Somewhat more moderate Republicans seek to provide competition among insurers by removing obstacles to the sale of health insurance policies across state lines.  Theoretically, this appears to be reasonable, however, there are a significant number of realities that make this an unattractive proposal.  The biggest one is that insurance companies establish provider networks where they operate.  Healthcare providers are not likely to want to participate in a network that is out-of-state, perhaps in a different time zone, when they need to have their billing issues resolved or if they need to seek authorization for patient care.  This is inefficient and costly.  Another major issue affecting consumers is relating to the need to, perhaps, sue an insurance company for denial of a claim.  Consumers would be subjected to the laws of a particular state which might be much more favorable to the insurance company in a classic David and Goliath tale.

 

I doubt there is anyone who disagrees with the idea that society functions better when people are healthier.  Employee productivity is increased, chronic healthcare expenditures are decreased, and individual satisfaction is improved.  The United States outspends every other developed nation on healthcare but has significantly lower health outcomes on almost every measure.  Civilized societies throughout the world recognize this.  In promoting the well-being of their respective nations, leaders have already debated whether healthcare should be construed as a basic right to be assured by government.  It has been unanimously affirmed by economically- advanced societies that some level of healthcare must be provided for each person as by doing so it benefits every person.  The United States continues to be an outlier.  If, by independent measures, it was demonstrated that our status as an outlier made the health of our nation’s citizens better it would make perfect sense to continue our current system of healthcare delivery.  Unfortunately, this is not the case on ANY measure of national health.  Republicans continue to refuse to acknowledge this and continue to permit healthcare to consume ever-larger amounts of spending and an ever-growing share of our gross domestic product (GDP).

 

It is obvious the Republican Party is incapable, or unwilling to, of addressing this.  We, the people, must continue to demand healthcare access for all.  GOP-led efforts to undo the most significant healthcare reform in a generation is harmful to patients, providers, and insurers.  These efforts undermine the healthcare infrastructure and will lead to a significant collapse that would cause all of us to suffer.  If we recognize that a healthy citizenry makes for a more robust society, we must not maintain the idea of healthcare as a commodity to be enjoyed only by those who can afford it.  Essential healthcare must be available for all people.  This must be ensured by government.