by Allen Barringer
For seven years now we have lived with “Obamacare,” the Affordable Care Act, and now we are engaged in rewriting it as the American Health Care Act, and, yes, it’s “all very complicated.” One thing already is clear: both Democrats and Republicans talk about “affordable, quality health coverage for all Americans” — but neither the ACA nor the proposed ACHA truly lives up to that description.
I understand that standards of health care are contentious. We don’t agree on what is “quality” or “adequate” care, let alone “humane,” and we don’t even agree how limited medical resources, such as transplantable organs, should be allocated. But until this year, I thought we did agree on equal access to whatever it is the government provides. If there is a health entitlement at all, it should be available to all.
Health care has long been a government responsibility. From medieval times, the established Church organized hospitals and administered the poor house and other components of the social safety net, while the King dealt with public sanitation, quarantines and military health. The Enlightenment brought about a greatly expanded government role in public improvements, including public health, during the 17th and 18th centuries. Those traditions were brought to the American Colonies; indeed, persons drafted for their medical skills were among the earliest settlers in Virginia and in New England. By the 19th century, and particularly after the Civil War, public health (including, individual care for the ill and the indigent) was generally recognized as a concern and a responsibility of the States.
In Virginia, the first mental hospital was built in Williamsburg in 1773 at the urging of Governor Fauquier, and Western State opened in Staunton in 1825. Jefferson’s Anatomical Hall, completed in 1826, was an early building for medical instruction at the University of Virginia. The Hampden-Sydney “Richmond Department of Medicine” opened in 1834, becoming the Medical College of Virginia in 1854. After the Civil War health activity in Virginia exploded due to the legacy of military health care and new learning about the importance of cleanliness, the source of infections and epidemics, and use of anesthesia.
Virginia’s State Board of Health came in 1872. Virginia mandated vaccinations and sanitary sewers and quarantine regulations in its port cities. In 1889, a young doctor recently trained in Vienna, Austria, in the latest medical and public health practices, was hired as Professor of Medicine at the University of Virginia. He quickly convinced Charlottesville and university authorities that to maintain the good health of university students and faculty it was necessary to address the health of the whole community they lived in. Eventually he persuaded the General Assembly to support this approach also. Teaching students through the practice of public health was the hospital’s mission. Teaching better health practices to the community and abating communicable disease at the source was its outreach.
Health care for the community means everyone in the community. Disease afflicts rich and poor and all races and occupations alike; every occupation has its hazards. The University hospital which Professor Barringer, my grandfather, founded and promoted so tirelessly was from its inception open to the Charlottesville community without regard for university affiliation, status, gender, race, or ability to pay. Many medical professionals and hospital administrators in Virginia still provide medical care on those principles, although they try to obtain payment when they can. And health remains an object of State concern and appropriations. For example, just a few months ago, Governor Terry McAuliffe announced State measures to make counteragents available at little or no charge aimed at combating the growth of opioid addiction, which he described as “a public health emergency” in Virginia.
The involvement of our state and federal governments in providing health care is so pervasive that we cannot pretend this is, “by default,” a private responsibility. The details of how the government goes about providing “affordable, quality health coverage for all Americans” are not as important as the affordability, the quality, the coverage offered. And this is a Virginia issue, not just a federal one.
Medicaid has a state budget impact, and there is talk of turning the entire health entitlement spectrum into federal block grants to the States. When McAuliffe tried to expand Medicaid under the ACA (essentially “free” to Virginians for a time, at the expense of the federal government), the General Assembly turned him down. That seemed to many observers (including me) to be more a partisan rejection of Obamacare than a vote against the public health and economic welfare of Virginians — but it certainly had the latter effect. And according to the Congressional Budget Office, the ACHA as proposed would substantially aggravate that effect.
Government support for health care has two rationales. One is economic. A healthy community is more productive, with less missed work, less down-time, less family distraction and dysfunction, and less threat of a catastrophic epidemic. Even if it isn’t you who is ill, you have an economic stake in the health of those around you, and you receive a direct benefit from the investment of your tax dollars in health care for others, not to mention the indirect benefit of a higher quality of community life. There is no distinction between individual health and public health in this regard.
The other rationale, of course, is compassion. Compassion is a moral imperative, and while I hear very little about compassion from Republicans these days it’s high time they re-discover it. The parable of the Good Samaritan is in the Bible, not a book of etiquette. Working in health care is an intensely rewarding endeavor, which attracts churches, charities, and all those many individual volunteers who devote their time to helping others. Not incidentally, compassionate policies also appeal to voters.
The problem with economic benefit and compassion as rationales for action is that both are open-ended. There is always something more that can be done to improve health, although at greater cost, with diminishing returns. And, each of us has some social (if not legal) responsibility for our own good health practices and diet. For these reasons “quality” care does not imply “unlimited” care; a health “entitlement” cannot be unconstrained. But constraining it by granting the entitlement in full to some people, denying it in full to others, is just not consistent with our American tradition of non-discriminatory, equal treatment under the law. There is certainly room to argue that our current entitlement programs are too generous; but whatever they offer should be “for all Americans.”
The ACHA does not reduce the level of health care for all; instead, it reduces access to health care for some. The way it proposes to retreat from “affordable, quality health coverage for all Americans” means some additional increment of the population will not have that coverage. The uninsured may nevertheless obtain crisis health care in crowded emergency rooms and, occasionally, free preventive care in community health clinics (although the ACHA would reduce government funding for those services also). The practical response of the educated taxpayer should be, emergency rooms are not free; we end up paying for them through inflated charges to those who have insurance, and we end up paying for the inefficiency of using hospitals for the delivery of community health care. In any event, not everyone can get the care they need from these crowded, stop-gap venues, which are increasingly inaccessible to many rural residents without transportation. We should rationalize our health care system by making quality care affordable, not by offering a lower quality substitute. But many taxpayers have not thought about this.
The denial of health care to some Americans and not to others certainly seems discriminatory to those affected by it. I have heard today’s two-tiered health system defended on grounds that the denial of access to “quality” care is not due to any legal barrier but mere un-affordability, and the government has no legal obligation to make things affordable – therefore, if the government provides some people with health insurance but not others, that’s tough luck, not discrimination. This disingenuous argument has been rejected many times in other discrimination contexts. Suffice it to say, if the withdrawal of insurance subsidies results in unaffordable health insurance which results in unaffordable health care, the result (I believe) is no less discriminatory than a law allowing health care only to those with certain income levels. One hoped-for result of “affordable, quality health coverage for all Americans” is to rationalize the way we charge and pay for emergency care and community health and regular health professionals, without hidden cross-subsidies and without discrimination based on ability to pay.
The bottom line: regardless of anyone’s legal right to “affordable, quality health coverage,” I believe we have to embrace some level of health entitlement for “all Americans” because, by choosing who can afford it, whatever the mechanism, the government also chooses whose health gets cared for, who gets denied care. And, that is a moral choice, not merely a legal one.
Are you willing that health care providers turn patients away if they cannot prove they can pay? Are you willing that your neighbor, whose financial resources have been exhausted by a chronic condition (that also prevents him from working), be told he’s simply out of luck? Does it matter if he brought this medical need on himself through addiction or neglect? If you say yes to any of these, do you accept that, if you ever find yourself in your neighbor’s position, you are asking others to treat you the same? That is what “affordable, quality health coverage for all Americans” really means.
Allen Barringer is retired and lives in McLean, Virginia.
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