By Michael L. Millenson
Sunday, June 8, 2008
On a recently posted YouTube music video, to a hypnotic bongo beat, rapper MIKE-E knocks out rhymes about . . . universal health care:
You are among the masses/One of 47 million people without health care access . . . Focus on the laws that must be enacted/Because we know there are flaws in our health care practices.
These may sound like lyrics only a lobbyist could love, but the video -- sponsored by the American Cancer Society -- expresses the frustration felt by those trying to end the United States's status as the only industrialized nation whose citizens don't have universal access to health care.
Here's a cold truth: Despite much media hand-wringing on the subject, most of us give about as much thought to those who lack health coverage as we do to soybean subsidies.The major obstacle to change? Those of us with insurance simply don't care very much about those without it. It's only when health care costs spike sharply, the economy totters or private employers begin to cut back on benefits that the lack of universal health care comes into focus. Noticing the steadily growing ranks of the uninsured, the broad American public -- "us" -- begins to worry that we'll soon be joining the ranks of "them."
News stories about the uninsured typically offer poignant profiles of people with whom the public can easily identify. As an award-winning article in Redbook last year informed its readers, "Increasingly, this is a problem for the middle class." Similarly, the Cover the Uninsured Web site, sponsored by the Robert Wood Johnson Foundation, highlights personal stories of seven appealing uninsured individuals. Several are current or former small-business owners. Six are white, and one is an African-American woman. There are no identifiable Hispanics.
The reality, however, is that only a minority of the uninsured are either the typical Redbook reader or that nice shopkeeper down the street. Two-thirds of those without health insurance are poor or near poor, according to the Kaiser Family Foundation. And there are clear disparities in how different racial and ethnic groups are affected. Only 13 percent of non-Hispanic white Americans is uninsured, compared with 36 percent of Hispanics, 33 percent of Native Americans, 22 percent of blacks and 17 percent of Asians/Pacific Islanders.
Politicians understand what this means in practical terms. If a lack of health insurance were truly a white middle-class crisis, then conservatives and liberals would long ago have joined together, carved out a compromise and done something. Instead, we're served a constantly recycled set of excuses for legislative stalemate.
The unofficial Republican attitude toward universal health care can be boiled down to the three "nots": not our voters, not our kind of solution and not our priority. None of the Republican presidential candidates even pretended to present a serious plan for universal coverage, nor did Republican primary voters demand one. The only candidate who had actually worked successfully toward universal health care -- former Massachusetts governor Mitt Romney -- apologetically disowned his own groundbreaking achievement. Presumptive nominee John McCain's recent health care proposal doesn't make anything more than a start toward covering all the uninsured.
Meanwhile, Democrats play their own "us vs. them" games. Although high-profile party leaders are loudly calling for universal coverage -- recall the Barack Obama-Hillary Clinton slugfest over their respective plans -- they reassure the middle class that the cost of compassion will be covered by repealing tax cuts for the wealthy. This "free lunch" approach may tax credulity, but it does avoid the need for discussing other taxes.
To be fair to the politicians, the interest groups representing the public have exhibited little appetite for genuinely grappling with the uninsured problem. AARP, one of the most powerful consumer groups, is running a high-profile ad campaign advocating a vague health care "reform." But imagine the revolt if the organization's leaders had asked its elderly membership to insist that those with no health insurance, including 9 million children, should be guaranteed basic care before Congress spent hundreds of billions of dollars adding a Medicare pharmaceutical benefit.
Though the American Medical Association has been a consistent voice for covering the uninsured, it reserves its political muscle for issues that excite its members. And the blunt truth is that the percentage of physicians who actually provide care to the uninsured or to Medicaid patients has been steadily declining for a decade.
When the American Cancer Society decided to focus its marketing budget on coverage for the uninsured, some supporters grumbled that it wasn't "our fight." The society responded that cancer patients without health insurance are diagnosed later and have a far greater chance of dying.
Other interest groups have been more likely to follow the AARP and AMA "stick to your knitting" model than the ACS one. Large unions advocate health care for all, but in practice, they're most concerned about maintaining benefits for their members. As a self-employed consultant who pays more than $1,000 a month for a very modest family plan (and am grimly happy to have even this), I have gazed longingly at the $25 per month that a friend who belongs to a municipal union pays for a far more generous plan.
When the general public talks about a health care crisis, what they're generally talking about is rising costs, a constant complaint since the Hoover administration (though Richard M. Nixon was the first president to officially declare a health care "crisis"). In response to this public clamor for cost control, those who advocate for the uninsured have decided to talk not only about the 22,000 of "them" who die annually because of a lack of access to care, but also to emphasize the money that providing coverage to "them" could actually save the rest of "us."
The Commonwealth Fund recently tallied the ways in which universal health care would save hundreds of millions of dollars, most of which were related to lowering the societal costs exacted by the greater burden of illness among the uninsured. The list was an exhaustive and exhausting one that nonetheless had the whiff of desperation, as if civil rights activists had appealed for support against segregation because it was reducing the pool of qualified candidates for the Selma, Ala., police department.
There are glimmers of hope. A growing number of insured families are struggling with higher co-payments and deductibles and skimpier coverage. These uneasy "underinsured" may yet join forces with the uninsured to demand protection from a situation that places them, as MIKE-E puts it, "One paycheck from poverty/One illness or injury from misery."
A survey last year by the Employee Benefit Research Institute found that more than two thirds of Americans were willing to pay 1 percent more in federal income taxes to make sure that everyone had health insurance. This counts as progress, as does the bipartisan Healthy Americans Act, a significant step toward universal coverage proposed by Sens. Ron Wyden (D-Ore.)and Bob Bennett (R-Utah).
Over the years, our society has gradually provided a medical safety net for the elderly and disabled (Medicare), the poor (Medicaid) and veterans. At one time, these commitments were controversial, and there's no doubt that they're expensive. Yet Americans from all walks of life understand that the true value of these programs must be weighed on a moral scale as well as a financial one. It's our willingness to be our brothers' keepers that in part defines who we are as Americans.
It has been nearly a century since Theodore Roosevelt, a Republican running unsuccessfully on the Bull Moose Party ticket, boldly became the first presidential candidate to promise universal health coverage. That was in 1912. Nearly a century later, we're still waiting for a leader with the courage and skill to break through our fears and successfully lead the charge up that particular hill.
Michael L. Millenson is a health care consultant and the author of "Demanding Medical Excellence: Doctors and Accountability in the Information Age."
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