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Obstacles to Reform

Health Insurance in America, part 1

I began researching and reflecting on the ethics of universal health care 20 years ago, when the Clinton administration initiated a failed attempt at reform. My interest in the project revived when President Obama began his reform in 2009, but after the passage of the Patient Protection and Affordable Care Act (ACA), it seemed — wrongly as it turned out — that a solution of sorts had been reached and the American public could begin to benefit from a more inclusive program of health-care benefits. Despite the exaggerated rhetoric of the opposition, the ACA offers only a temporary and unwieldy fix rather than a program that will effectively cover a much larger percentage of Americans without unduly raising costs.

Conservative opponents often claim that a majority of Americans are not in favor of the ACA; if that is true, it is only because a significant number of people think that the health-care reform is too weak, an understanding that adds to the confusion and difficulties of the patchwork system that has evolved. As with the need for tax reform, the ACA’s lack of simplicity is largely the fault of the opponents of reform, who often fight to maintain the provisions, exceptions, and distortions built into the tax code by special-interest groups; so the confusing and complex health care system is the result of significant opposition to an efficient, simple, and universal system.

As a hint of a much larger project, I offer a two-part series on health insurance in America. In this first part I try to look realistically at why reform should be so hard; and in the second part I offer the reader as persuasive a case as I can for the moral imperative of a system of universal health care, based on biblical, theological, and practical arguments. Since many readers of The Living Church are likely conservative in their politics, the case is fashioned to address those who do not consider themselves liberal, and who start from a position of skepticism with regard to government programs and the modern welfare state.

It was Bismarck, chancellor of Germany, who in 1883 instituted the first compulsory national health insurance program. Today it is not clear whether the modest reforms of the ACA will be allowed to go into effect in all areas of the United States. This is not only a case of the need for Congress to pass the funding provisions, but of the need to overcome the strenuous opposition of state governments and their reluctance to cooperate in implementation. And behind this stands the challenge of securing genuine acceptance among the citizenry.

Authoritarian states such as Bismarck’s Germany, and the more progressive northern European countries, have found it easier to introduce comprehensive programs than have countries in the Anglo-Saxon free-market economic and political tradition. Britain founded the National Health Service in the late 1940s, Canada had a rocky start with national health in the 1960s, and it was still later (1984) that Australia made the move.

Americans place an even higher value on individual freedom than these other English-speaking countries, which generally share the same philosophical, political, and legal traditions. Fairness and Freedom by David H. Fischer brings out this theme well by comparing the choices of the United States and New Zealand. Societies must balance the coercion and funding required for constructive social programs with the maintenance of individual freedom, which remains the point of contention. Tea Party supporters and others have wanted that line drawn at a distinctly libertarian point on the political spectrum. And yet there is something exceptional about the challenge of national health care, because the United States has developed other features of a modern welfare state such as universal education, old-age pensions, safety nets for the disabled and very poor, and so on.

In five eras of the last century a national health program for Americans was proposed with genuine hope for reform. The first serious proposal for national health insurance began in the era of Theodore Roosevelt, alongside the institution of national income tax. In the New Deal era Franklin Roosevelt had opportunity and incentive to develop national health care, and a team drew up proposals, but he felt that championing it might risk the failure of other key legislation. In turn, for Truman in the 1940s, the Clinton presidency around 1993, and the Obama administration in 2008-09, public support for substantial reform, including government insurance programs, began at high levels. In 2009, before the Obama administration struck a deal with the insurance companies and withdrew it from the discussion, support among Americans for a single-payer system was amazingly high.

Health-care in America may be analyzed in terms of three causes or elements, incorporating both historical and contemporary factors.

1. Employers have provided health insurance fragmentarily, as a part of piecemeal reforms in the last half-century. Health insurance as a benefit of employment developed rapidly during World War II when companies could not raise wages but offered insurance as a competitive benefit. Such insurance is now the standard way to provide coverage for those with full-time jobs. But many self-employed, retired, disabled, partially employed, and unemployed persons, and their children, find themselves without coverage.

The Medicare and Medicaid programs of 1965 provided basic health coverage for the elderly and the very poor. Other programs have followed to provide for children (CHIP) and for those who lose their employment insurance and need temporary coverage (COBRA). The extension of coverage for young people up to age 26 under their parents’ policies marks a more popular feature of Obamacare; but what about young people aged 27 or 28 who may not be employed? Meanwhile, even the solidly employed middle class often finds itself hindered from seeking other work for fear of losing coverage, thereby reducing the job mobility that a truly free-market system requires.

Such an ad-hoc approach to healthcare, with minimal government involvement, produces considerable complexity and confusion, even as it leaves many without coverage. And this remains true under Obamacare: even if the ACA enjoys the success hoped for by its most optimistic supporters, at least 5 percent of the U.S. population will not be covered adequately.

2. Americans lack universal health care partly due to a lingering ethos of voluntarism, incorporating nostalgia for the country doctor, hospitals run by charities, and funds generated by community spirit. When a child contracts cancer, or needs an expensive operation, community sympathy and response is often generous, and we are inspired by these stories of community support. But is this the best way for society to deal with expensive medical needs? In fact, we rely on emergency wards to take in the indigent, with large medical bills often unpaid and families bankrupted or severely stressed. In turn, the cost of the treatment and hospital expense are covered through higher charges and premiums for those with insurance.

From the time of Alexis de Toqueville commentators have noted the volunteer spirit as a strength of American society, but sometimes it works against effective, long-term solutions. During the polio epidemics up to the 1950s, volunteers and charitable organizations provided much care and equipment, with the aim that no victim of polio would go without treatment. While admirable, the success of these efforts led many to believe that volunteers and charities could take the place of government, delaying for a generation the sense of need for comprehensive reform.

3. Discussion and debates in the 1940s, 1990s, and since 2009 have been subject to distortion and scare tactics. In 1943 there was strong public support for government-sponsored health insurance in California, and the state medical association hired advertisers to develop an opposing campaign. The Whitaker and Baxter agency widely distributed a pamphlet purporting to use a quotation from V.I. Lenin: “Socialized medicine is the keystone to the arch of the communist State.” The quotation was bogus, fabricated by manipulators of opinion.

Time and time again, strong interest groups — not just the American Medical Association but businesses, including especially pharmaceutical and insurance companies — have cast the issue of national health insurance in ideological terms (as in the Truman era’s Cold War rhetoric of “better dead than red”), or to play on fears of government takeover and bureaucratic complexity. These tactics have succeeded in changing the collective mind of the citizenry from initial cautious support to suspicious opposition, amid an atmosphere of confusion and uncertainty.

Perhaps the most potent fear that has shifted popular opinion about health-care reform concerns an anticipated worsening in the quality of health care for those with insurance. Rationing, or restrictions of choice of physician, with less generous coverage and more expensive premiums, are frequently adduced as likelihoods, or even present realities. The “Harry and Louise” ads of the 1990s had a measurable effect in creating an atmosphere of doubt and vague fear that couples or families happy with their current coverage would be worse off after the proposed reforms of the Clinton administration.

There is very little we can do about the piecemeal history of reforms to this point. Thoughtful citizens, however, and Christians in particular, have a responsibility to think carefully about the reasonable roles of government, and to resist forces that reduce the quality of debate, often due to cynical self-interest rather than concern for the common good, that is, the whole society.

In the second part of this essay, I will outline a moral argument for why American Christians should make universal health care a priority.


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