Buried in the President's State of the Union speech last week was the most significant statement that a Republican President has made about health care.
The magic words: "Good health care is every American's right."
That may sound like innocuous rhetoric. But to experts in the field, the phrase "right to health care" is a code phrase for one of the most divisive political issues in American medicine.
For decades, labor organizations and liberal Democrats have made the concept of health care as a basic right the cornerstone of their political philosophy. Advocates of major reforms in health care argue that the government is responsible for guaranteeing that right and should take the dominant role in organizing, funding and providing medical services so that all Americans can be assured of access to an adequate level of care.
The Bush administration, along with most Republican leaders, has remained adamantly opposed to national health insurance or other dramatic changes in the current free-enterprise system of medical care. So much so that up to now they have carefully avoided the sensitive question of health care as a fundamental right.
Just how sensitive the issue is became apparent during the Reagan administration, when a special presidential ethics commission concluded in 1983 that the federal government has an ultimate responsibility for seeing that an "adequate level of health care" is available to all Americans. The 11-member panel -- which contained eight Reagan appointees -- shied away from declaring that a "right to health care" exists. But its report defined society's ethical obligation regarding access to health care -- and set off a storm in medical circles.
Since then, there has been very little public debate over health care as a right. George Bush has always seemed ill at ease talking about it. "I think everybody should be healthy," he said less than a year ago when he was asked about health care as a right. When pressed whether he thought Americans have a basic right of access to care, he replied: "I would think so, yes. But that doesn't mean that I think the federal government is the only way to do it."
In this context, the President's statement last week is a bold one and has raised a few eyebrows. While it's not clear how well he understands the implications of his remarks, the President is now on record as endorsing the principle that health care -- good health care, in fact -- is a basic right for all Americans.
"It's a step," said Gail Wilensky, administrator of the Health Care Financing Administration, which oversees the government health programs of Medicare and Medicaid. "The principle is established. Every American should be able to get necessary medical services. That's goal No. 1."
Of course, Bush's statement is still a long way from the White House's embracing some form of national health insurance. The administration is firmly committed to the current system of private health insurance and independent hospitals and medical facilities. There is also a certain skepticism that any real health care reforms will be forthcoming from this Presidency. If the President has drawn a line in the sand about health care as a basic right, he has hardly issued a call to arms to back up his statement.
There are no major initiatives in next year's budget to address the problems many Americans have in exercising their right to routine medical care. More than 30 million Americans are without health insurance, up from 20 million a decade ago. In last year's State of the Union message, the President asked the Secretary of Health and Human Services to review the "quality, accessibility and costs" of health care in this country and come up with a strategy to address the gaps in coverage and services. While HHS Secretary Louis W. Sullivan has talked about the principle of universal access to care in the last several months, that key study is still underway and probably won't be ready until midyear.
Meanwhile, the White House has limited its health agenda to promoting fitness and "good health" behavior -- just saying no to drugs, booze and cigarettes, eating the right stuff, exercising regularly.
For those in the medical trenches, the President's focus on promoting better personal health habits is starting to wear thin.
"Getting people to stop smoking doesn't deal with the deficiencies in the health care system," said Howard H. Hiatt, professor of medicine at Harvard Medical School and School of Public Health.
"Prevention is part of what we can do to improve the health of the American people, but it isn't all," said Marc Rivo, deputy administrator of the District Commission of Public Health and president of the District of Columbia Academy of Family Physicians. "The other part is access to basic care for diagnosis and treatment."
A recent study by Rivo and other District health officials found that thousands of Americans die every year needlessly from 12 diseases that can be treated or prevented by routine care. Blacks have significantly higher death rates from these illnesses than whites -- largely because more of them tend to be poor and lack medical coverage.
Obviously, rugged individualism can only go so far in public health. To begin with, some individuals are more rugged than others either because of their genes, their economic status or their luck. A narrow strategy to prevent disease fails to take care of people who are already sick and in need of care. It also raises moral questions about those who get sick, blaming the victim for developing colon cancer, for example, because the person didn't eat enough fruits and vegetables.
No one can argue with a healthy lifestyle. Nor is there any argument with efforts to reduce high-risk behaviors such as smoking, drinking too much, abusing drugs, not wearing a seatbelt.
But moral sanctions against bad health are not enough. It's a welcome step that President Bush has endorsed the principle of access to health care as a right. But if that is all he does in the health care arena, he is saying, in effect: "Let them eat broccoli."