Murphys, CA…Introduction: The United States is alone among industrialized nations in using wealth as a gatekeeper for access to health care. The wealthier you are, the more and better health care you get. The national debate that is now taking place focuses on whether every individual, irrespective of their income, should have access to great health care.

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The United States is alone among industrialized nations in using wealth as a gatekeeper for access to health care. The wealthier you are, the more and better health care you get. The issue isn’t about efficiency (keeping costs down) or efficacy (performance), it is about whether you have the financial wherewithal to be able to see a doctor, have surgery, visit a mental health professional, or afford prescriptions. The national debate that is now taking place focuses on whether every individual, irrespective of their income, should have access to great health care.

From Medicare to Obamacare

Before 1965 and the creation of Medicare and Medicaid, if you were elderly or very poor, the answer was definitively no. In 2003, President George W Bush signed legislation to expand coverage to include prescription drugs. But the working poor, those working for small companies, individuals with pre-existing conditions, students, and those seeking employment — a population in the tens of millions — were still not covered by these programs. The Affordable Care Act (ACA) of 2010, more popularly known as Obamacare, sought to address these concerns by mandating increased coverage for those with pre-existing coverage and a host of other changes.

Trumpcare

The House of Representatives recently voted by the narrowest of margins (217-213) to radically alter Obamacare. While the primary associations of doctors, nurses, hospitals, and mental health professionals have been quick to criticize what is becoming known as Trumpcare, most Americans are confused by the bewildering debate and changes in insurance plans. Over the next several months, while the Senate and the Congressional Budget Office weigh in on what House Republicans have adopted, it is time to consider why coming up with a good health care system is so contentious.

The Republican plan, known as the American Health Care Act (AHCA), would provide tax credits in lieu of subsidies for insurance premiums, eliminate Federal mandates for insurance coverage, establish high risk insurance pools for those with pre-existing conditions, provide limited underwriting of these pools for a short period of time, and authorize health care savings plans. In its original form, the AHCA flamed out when the non-partisan Congressional Budget Office (CBO) forecasted that 24 million people would lose health coverage by 2024. (CBO March 13, 2017). That does not include the 28 million citizens without insurance today. Even with this projection, the most conservative wing of the Republican party known as the Freedom Caucus rebelled against any protection for citizens with pre-existing conditions. Because the House rushed the adoption of the latest version of the AHCA, we will have to wait for a revised CBO analysis. But, even an early reading of the bill reveals that the numbers of those who will lose their health insurance will be substantially higher. The AHCA is opposed by the American Medical Association, The American Hospital Association, and the Catholic Health Association. Republican Senate leaders have already indicated they will ignore the House bill and write their own.

California’s Single Payer Proposal

In California, legislators are moving forward with an alternative to all of these programs with a proposal to create a single payer health care system for all residents of California. (CA Senate Bill 562).

The Great Question

The difference in these programs and proposals mirror the divisive debate in America on how (and whether) everyone in our society can (or should) have the opportunity to live longer, healthier, and satisfying lives without creating a burdensome regulatory environment and bureaucracy to administer this opportunity.

What We Need to Know

The challenge of health care governance for policy-makers and politicians, as well as the general public, arises from: a.) a lack of knowledge about how the health care system works; b.) the lack of consensus over goals and objectives for health care; and c.) fundamental differences in what role the government should play in health care delivery. For something so vital to all Americans, these are big problems.

How Little We Know

First of all, most of us do not appreciate just how complicated health care is and how little we know about its cost and performance. Consider the fact that the United States spends $600 billion for defense (armed forces, civilians, equipment, operations), while, at the same time, we spend nearly 8x more — $4.6 trillion — for health care services (doctors, hospitals, drugs, long-term care). Ironically, there is more publicly available information about the fire and flight control problems of the Pentagon’s F-35 Joint Strike Force Fighter than about the effectiveness of cancer treatments.

Healthcare is a Question of Ethics

Second, the goals and objectives of health care services are not only economic (how much) and political (who controls) questions, but emotional and ethical ones as well. Consider the decision process about a patient with catastrophic anoxic brain injury (i.e., persistent vegetative state). Whether the doctor (for reasons of viability), the patient’s family (for hope), the government (for policy), or the insurance company (for cost containment) makes the decision to terminate life support, it is still an ethical choice. This decision matrix complicates many, if not most, health care related decisions.

Who Makes the Decisions

Third, this leads to the question of who makes this kind of decision. Most people, if asked, would assert it should be the patient or his or her family. But in many cases, the final decision is made by those paying for the care: the hospital, insurance company, or the government. From its inception until the end of 2016, half of the country opposed Obamacare largely around concerns about the insertion of the Federal government into healthcare decision-making. By the beginning of 2017, twenty-five million Americans had been given access to health insurance through Medicaid expansion, insurance subsidies, or direct purchase and the latest Gallup poll now shows that 55% of Americans support Obamacare, while 41% oppose it. (Gallup April 4, 2017). Opinions shift relative to perceived value.

In the Coming Weeks

In this series of columns over the next month, I will examine why health care, as policy and as practice is so complicated, why we as Americans are sicker and die earlier than residents of other countries, why our health care is so expensive, why the answers to these questions have a particularly grave importance for rural America, why the system that Obamacare tried to fix was so broken, and finally, the political question of whether health care is a right or responsibility.

[To be continued next week]

The copyright for this series of articles is held by John MacWillie and is licensed for distribution without royalties for non-commercial use under a Creative Commons License with the restriction that the content is copied in-whole and sole attribution for authorship is prominently displayed consistent with the title of individual article(s) or the entire series.