While in Toronto, I participated in a symposium entitled, “The Implosion of the Health Care System — Implications for Psychologists”, which focused on the impending American health care crisis. Three of the five panelists provided reasoned and compelling arguments for radical change in the way health care is delivered and paid for in this country. I was the last presenter to speak at the symposium. It was my job to speak to the role played by politics in the health care reform equation. I delivered a rather gloomy report, I must admit. Just when the party was really starting to heat up, I came along and pulled the plug on the band. Sometimes reality does bite.
I am writing this on Labor Day, as political leaders make their rounds and shake hands with voters. Their speeches drift from celebrating workers to weighing in on the recall circus in California. Few, if any, will address the most pressing issue affecting working families today: affordable health care. A vast majority of the uninsured are workers and their families. Insured workers aren’t doing much better with double and triple-digit increases in their monthly premiums, skyrocketing deductibles and greater out-of-pocket charges at the doctor.
Isn’t it time for the most advanced nation in the history of the world to provide affordable care for every one of its citizens? Don’t be too quick to suggest that there is unanimity of response to this question. The answer, in fact, depends almost entirely on the particular ideology to which you subscribe.
Despite substantial evidence suggesting that nationalizing health care might very well make the most sense for Americans, political forces weigh heavily against such a system currently. The United States is unlikely to embrace universal health insurance for this country soon, if ever. Why is this so? Because, among many reasons, neither moral sentiments among a majority, nor political pressure from the uninsured, nor pure economic self-interest of those who would have to pay added taxes for it, furnishes the requisite political force to induce a majority of the nation’s political leaders to embrace that idea. Admittedly, this is a pessimistic conclusion, but looking at the past four decades of U.S. health policy makes that conjecture a good wager.
Since the passage of Medicare in 1965 (which was a substantial change, but restricted to only Medicare and as such affected only a part of the wider health system), every attempt to inject major health care system alterations has failed. All of us remember President Clinton’s debacle only ten years ago. Five years prior to that, the Medicare Catastrophic Coverage Act (a substantive medicare reform measure) was actually passed, only to be repealed a few short months later due to the huge public outcry from elderly beneficiaries who were furious after they started to look at the details of the bill.
You probably know that Congress is currently supposedly well on the way to passing an historic Medicare law that will, at long last, overhaul the huge government health insurance program and offer new drug benefits to 40 million elderly and disabled Americans. Lawmakers began meeting during the August Congressional recess to begin hammering out the differences between the bills already passed by the House and the Senate. It would seem that all they have to do is split the difference in time-honored legislative style.
Maybe, but here is the pessimistic view: That the differences at stake here are not the ordinary stuff of legislative compromise. That the conservatives in the House and the liberals in the Senate have profoundly different visions of Medicare, of social welfare programs and of government in general. And that those divisions will be hard to finesse, despite the efforts of centrists and pragmatists, like recent AAP honoree Senator John Breaux, in both parties, and the urgings of a White House intent on resolving the drug issue before next year’s election.
Can you simply split the difference when the two ideological camps are so profoundly at odds on the efficacy of government itself? One side sees middle class entitlements, like Social Security and Medicare, as enduring achievements of government at its best; the other as promises that cannot be kept unless the programs are modernized, reinvented to allow more competition and private market involvement.
Similarly, liberals increasingly see tax cuts as a calculated attempt to starve the government, and by extension, relentlessly trim its services; conservatives see tax cuts as empowering, taking money from a bloated bureaucracy and returning it to the taxpayers.
Medicare, and by extension, any move to nationalize healthcare is the battleground for this much broader struggle.
Conservatives argue that the program is a relic of the Great Society, a collection of government bureaucrats rigidly administering prices for an oncologist in Des Moines and a hospital in Houston. Moreover, many conservatives maintain, the program is not affordable, given the huge wave of 76 million baby boom retirees just over the horizon, and the ever growing costs of medical care and new technology.
Conservatives say that competition and private market forces will, eventually, do a better job of containing costs and serving beneficiaries than a centralized government bureaucracy ever could. If they lose this, conservatives argue, the traditional vision of a government-run social insurance program will not only endure, but prevail. Some say, Congress may never get another chance to “reform” Medicare because the closer the powerful baby boomer voting bloc gets to retirement, the harder it will be to do anything that seems to restrict its benefits.
In short, this is the proverbial fork in the road of history. This is not something where you can just say, “Let’s strike a deal.”
Liberals, on the other hand, see Medicare as an extraordinarily successful government program that lifted the elderly out of the charity wards and into the mainstream of American medicine, a middle-class entitlement that reminded Americans of the good that government could do. From its start in 1965, Medicare has performed a role that government is uniquely suited to, liberals argue — spreading the risks and the benefits, protecting a vulnerable population.
Even so, leading Democrats in the Senate, including liberal patriarch Ted Kennedy, say they are willing to accept modest structural reforms, and yet another experiment with private health plans in Medicare, in exchange for finally adding drug benefits. After all, they are acutely aware that Republicans control the House, the Senate and the White House, and that prospects for Democrats’ recapturing any of the three next year are — to put it kindly — hardly a sure thing. Another chance at $400 billion for drug benefits may not come along soon.
So leading Democrats signed on to a bipartisan compromise bill in the Senate, where the Republicans have a tiny majority but rules give the Democratic minority much more influence than they have in the House. But the party’s liberals have drawn the line at the House bill; its competitive provisions are unacceptable to them.
The pragmatists argue that there is a “third way” on Medicare; a “down payment” on drugs for the left, a demonstration project on competitive health plans for the right. In fact, that may be the compromise that emerges, producing a law signed by a cheerful President Bush before a happy bipartisan audience.
But there is another view in both camps: That there are no win-win solutions here. That if Medicare legislation is finally passed, one world view will have won, the other lost. That you cannot split the difference when the two parties are so profoundly at odds on government itself. If history is any indication of the future, that may well be the fate of the current Medicare reform attempt.
Although the political deck seems powerfully stacked against universal health insurance or any radical reform to the system in the United States, every so often the stars do align, to make breakthroughs in public policy possible. It was so with the original enactment of Medicare in 1965, with the enactment of the seemingly doomed 1986 general income tax reform legislation, and with SCHIP in 1997. As champions of health care reform, psychology will continue to press our legislative agenda with our friends on Capitol Hill as well as attempt to broaden relationships with those legislators who may not yet fully support mental health initiatives. It is the health policy analogue of permanent military preparedness.