Janie and Charlotte are best friends from college who have diverged spiritually and politically until we don’t agree about anything (almost). But as friends, we occasionally get together to talk over some of the issues of our time. Our first discussion was about religious liberty, beginning here. Today we begin a debate about a very hot topic soon to get much hotter.
Introduction
One of President Obama’s most significant achievements was the Affordable Care Act, which expands medical coverage to several million previously-uninsured Americans. But it’s also one of his most controversial acts, and soon to be much more so when the Republican congress, with the backing of a Republican president, tries to make good on their long-standing promise (or threat!) to “Repeal and Replace.”
Rather than try to parse out the pros and cons of every detail of the ACA and the proposed replacement (whenever we get to see it), we’re going to start with the basics:
Do we agree there is, or should be, a basic right to healthcare?
Janie: I’ll go first, and my answer to that question may surprise you. From the heights of conservative
ideology, I would say no. Health care (actually it’s mostly sickness care, but I guess we’ll agree on the accepted shorthand) is what political theorists would call a “positive” right, meaning that if you don’t have it someone has to provide it for you. America was founded mostly on “negative” rights, meaning government should not interfere with a citizen’s individual choices as long as the person isn’t breaking any laws or interfering with another citizen’s rights.
But as time goes on it’s not that simple. First, advances in medical knowledge and technology mean that specific treatments can mean the difference between life and death. This sharpens the distinction between income levels. (In the past, the rich could afford medical care, but the state of medicine was such it was often healthier to go without!)
Second, a general breakdown in family and community cohesion means we’re not as available to care for each other, and the care we can offer is limited. When our country was founded, towns and neighborhoods tended to be more tight-knit and basic needs for the sick could be supplied by people who knew them. Most if not all hospitals were founded and maintained by churches or other charitable organizations.
Now, of course, the situation is very different. Ideology bows to practicality, not to mention basic human decency. So I would say, yes, there is justification for claiming a basic right to healthcare. The question is how to provide it.
Charlotte: In America, citizen “rights” first were claimed in the Declaration of Independence.
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed…
I love these words! I love that the DNA of our nation imprinted the ideal of human rights within our body politic from our very inception. But all of us who know American history, know our society has lagged behind our ideals over and over again.
Even as our Founders signed their names to this bold document, we know their wives and daughters did not (and would not) have those same rights and their slaves were not even considered to be fully human. Even though the Founders amended the original Constitution with the Bill of Rights (another brilliant document), we know it has taken years for the people of this nation to come to any kind of agreement about what some of those rights ought to look like in the lives of real people.
The Constitution and the law of the land did not assume slaves should have the right to freedom; America came to that conclusion slowly and violently.
The Constitution and the law of the land did not assume women should be free to vote and own property; American came to that conclusion slowly and reluctantly.
The Constitution and the law of the land did not assume Black citizens should have rights equal to White citizens; American came to that conclusion slowly and with much activism.
The Constitution and the law of the land did not assume all children should have free access to a basic education; America came to that conclusion slowly and awkwardly.
So I have to agree with you that health care was not one of the “positive rights” listed in the founding principles. But I will argue that affordable access to health care surely fits appropriately within the “life, liberty and pursuit of happiness” paradigm. I also argue that much of America is finally coming to the conclusion that basic health care ought to be part of the “general welfare” promoted by government – one more step in our evolutionary process of “forming a more perfect union.” I say it’s high time.
Janie: Well said! And don’t look now, but I think we agree so far!
As I mentioned above, because of 1) medical advances that sharply delineate the difference between rich and poor and 2) a breakdown of family and community cohesion that leaves many people without care support, governments have “grown” an obligation to provide some sort of care. The vast majority of Republicans, both citizens and politicians, agree with this too.
I’m glad you mentioned the preamble to the Declaration, because among those inalienable rights is liberty. Opponents of the ACA oppose it not because they want to see sick people die but because it interferes with liberty. For every one of the ACA’s 2100 pages (actually, I never heard what the final count was) the health care system and its patients (or victims, some would say) are saddled with another ten pages (more or . . . more) of regulations that interfere with the physician’s liberty to practice and the patient’s liberty to choose. And you remember the promise “If you like your plan you can keep it”—there was no way that could be true with the law as conceived. It forces a large, diverse, dynamic population into a narrow channel and presumes to make vital decisions for them.
So that may be the real issue—not a right to life, which is a claim on the government we agree citizens have. But what about the right to liberty? That’s where the rub comes in. Are “life, liberty, and the pursuit of happiness” listed in order of priority? (Does “life” trump “liberty”?)
What do you think? That’s my first question back to you.
And also, if I may, one more. Health coverage did not used to be beyond the average American’s reach. When I was 12, I became dangerously ill with myocarditis and spent a whole month in Dallas Children’s Hospital. We were a low-income family: my mother was the only wage earner at the time and women didn’t make much, especially for general office work. But she had Blue Cross through the Dallas Teachers Credit Union where she worked, and though I’m sure the family was pinched, we didn’t suffer.
That was in 1962. Since then, costs have escalated far above the rate of inflation. Why do you think that is?
Charlotte: “Life, Liberty and the Pursuit of Happiness…” You are wondering if these were listed by the Founders in order of priority? No, I don’t think so. You and I are both writers and what I see is poetic rhetoric. The Declaration of Independence gives us stirring language that lifts up our lofty ideals as a people. It’s also interesting that the Preamble says these three are just some of the “inalienable rights” endowed by the Creator. The Founders left the door open for America to continue to name and ensure basic rights for its citizens.
In this debate, in my opinion, it comes down to the difference between two visions: a capitalist individualist society or a connected community. Are we to give the market place unfettered freedom to operate our health care industry as a for-profit business? Or are we going to craft a society that requires the health care industry to put people over profit? Are insurance companies and corporations really “people” with rights that are more important than the rights of regular people to access basic health care?
I didn’t know this story about your myocarditis. Wow. Scary. I’m so grateful you were able to get the treatment you needed and have lived such a valuable productive life. I’m so glad we’ve been able to be friends all these years since.
Children’s Medical Center and Parkland Hospital are great examples of non-profit hospitals that put people over profit. I did my chaplaincy internship at Parkland and was very impressed with the work they do. These hospitals and their associated clinic systems serve anyone who has a need – no matter their financial situation. I don’t really understand all the funding and how that works but these are critically important services for Texas residents and countless people are still alive because of this access to affordable health care.
Janie: Absolutely! And I’m glad I was living in 1962 rather than 50 years earlier when treatment might not have even existed. The point is, insurance was affordable when we needed it back in 1962, even though we were a low-income family. Things have gone off-track since then, for various reasons I’ll mention.
But here’s a little-known, or at least not much-discussed, problem: non-profit and rural hospitals are actually closing because of the ACA. In Springfield, MO, Ozarks Community Hospital closed its Emergency and Surgical facility because the administration put too many requirements on it. Not reasonable requirements—a friend who worked as an emergency nurse there said that as soon as OCH met one list of demands it was slapped with another. OCH was built specifically to serve lower-income, lower-educated people of the Ozarks that larger hospitals didn’t want. He believes this was a strong-arm tactic to force those patients into larger hospitals with more money.
In rural communities, at least 80 hospitals have closed since 2010, one of them not far from me. As I understand it, the reason for rural closures is that these hospitals accepted a $155 billion cut in Medicare/ Medicaid payments with the expectation that all the new Obamacare enrollees would make up the difference. That didn’t happen, and when the ACA didn’t meet its funding goals it shuffled thousands of Obamacare patients back on Medicaid, which pays hospitals far below their costs. Unable to meet operating expenses, they simply closed. Obviously this was an unintended consequence, but a very real one to thousands of rural residents living 100 miles or more from a hospital.
Charlotte: You claim the ACA is hindered by “…regulations that interfere with the physician’s liberty to practice and the patient’s liberty to choose.” I say this problem is much greater when insurance companies operate without proper regulation. “Regulations” in fact are “protections” for the people against the abuses of corporate interests. This problem in the ACA can be addressed and improved.
Janie: Maybe so. But did you happen to catch the debate between Bernie Sanders and Ted Cruz on CNN last Tuesday (Feb. 7)? Cruz brought up an important point: the Big-player insurance companies like regulations because they can absorb them, even negotiate for exemptions if they need to, while the smaller companies are sunk. As competition declines, costs go up. And regulations are not always protections.
Charlotte: You say the ACA: “…forces a large, diverse, dynamic population into a narrow channel and presumes to make vital decisions for them.” What was happening before the ACA disallowed insurance companies from imposing lifetime limits and refusing pre-existing conditions? Who was making vital decisions then?
But I love your phrase; yes we are a “large, diverse, dynamic population…” One of America’s greatest strengths. I don’t see the problem the way you do; I see the ACA as forcing insurance companies to provide a wider kind of coverage that attempts to address some of this diversity.
Janie: I don’t see diversity as a problem. So I wonder why Obamacare prescribes a one-size-fits-all solution by requiring all insurance to cover a wide-ranging “essential benefits package” for everyone, whether they need it or not: maternity care for retirees, for instance. I assume the purpose of that is to spread the burden equally, but I think there are other ways to do it besides making the young and healthy shoulder some of the costs for the old and sick—especially if we bankrupt ourselves to the point where the funds won’t even be there when today’s young people need it.
Charlotte: You ask why health care costs have escalated. That is way out of my field of expertise but I suspect there are quite a few people in the system getting filthy rich from the suffering and ills of Americans. (Follow the money!) As I understand it, medical procedures and medications are far less expensive in many other countries, nations that have made the choice to count health care as a basic right and have figured out how to offer it to all their citizens.
Janie: I did a little research through several (not all conservative) sources and came up with these reasons. There may be more:
- The upside to R&D is the development of new drugs and treatments with the potential to relieve suffering for millions. The downside is that it costs money (including obscene profits).
- Hospital costs. Related to technology, but also to administrative costs. Every hospital hires a battalion of staffers just to deal with insurance companies, another to deal with government paperwork.
- Administrative costs to private physicians. Ditto, on a smaller scale.
- More people living longer with chronic conditions.
- Lifestyle choices. Ours is a self-indulgent society that (at least over the last 30 years or so) tends to slough off responsibility. At the risk of sounding like I’m blaming the victim, here’s a story. My friend who used to work at the nonprofit hospital kept seeing this same woman over and over. Her issues were legion, and I’m sure some of them were unavoidable. She was also terribly obese and smoked like a chimney. When he asked why she wouldn’t take care of herself a little better, she told him, “Because I can come in here whenever I want and you people have to take care of me.” I have no idea how widespread this attitude is, but I know it’s out there.
I’m just saying, we won’t know how to fix the problem unless we understand where the problem is.
Charlotte: Wouldn’t it be nice if America could stop waging war all over the globe and spend that money providing affordable health care, excellent public education and clean water to everyone?
You say: “…governments have ‘grown’ an obligation to provide some sort of care. The vast majority of Republicans, both citizens and politicians, agree with this too. The question is how best to meet that obligation.” This statement intrigues me. Many of my progressive friends will doubt your claim that “the vast majority of Republicans” recognize some governmental obligation to provide some sort of care. How can you help us believe that?
Janie: Of course they doubt it. Haven’t they always heard that Republicans only care about rich people? Republicans are a mixed bag, just like Democrats, but let’s assume they aren’t totally stupid or suicidal. Pulling the insurance coverage from under millions of people would be political suicide. The hope is to replace the ACA with something more affordable and more efficient–and some Republicans may even have human reasons for doing so!
Charlotte: And when we talk about “how best to meet that obligation,” will you claim that private insurance companies and their corporate interests is a better approach than governmental insurance plans? I sure do like my Medicare insurance. It is efficient and affordable. Why can’t everyone buy in to this kind of program?
Janie: That’s a good question. In the Cruz-Sanders debate, Bernie Sanders said repeatedly, “We’re the richest country on earth, yet our health-care costs are twice as high as any other developed nation.” He seemed to think that statement was an argument, and elsewhere he implied (or explicitly stated) that the wealthiest Americans should make less money. Even if the wealthiest Americans made less money, even if all their money were confiscated to provide healthcare for Americans, it would only supply the need for a limited time, and then what? There are more options than “private insurance companies and their corporate interests.” I’m hoping we can talk about that next.
In the meantime, I think we basically agree on the original question: Should there be a basic right to healthcare for Americans? My ‘yes’ is a little more cautious and qualified than yours, but it’s still a Yes.