I received a nice birthday present this morning: the news that the health reform bill passed last night. This is good. The reason I think it’s good has nothing to do with the merits of the bill itself, which may turn out to be a disaster for all we know. (I don’t think it will, but only time will tell.) No, my reason for applauding last night’s development is this: it shows that our system of government works. It’s messy, inefficient, frustrating, and convoluted. Sometimes it’s downright disgusting. It’s prone to displays of ignorance, immaturity, bigotry, and misplaced anger. It breeds demagogues. It fosters hypocrisy, cynicism, pettifoggery, and foolishness. All these traits of political character are magnified by constant media attention, which then breeds more foolishness, pettifoggery, cynicism, and hypocrisy. In a vicious spiral. Ever downward. Or so it seems.
But despite its many flaws, our system of government has this redeeming value: it permits us to resolve questions of public policy without resort to violence, coups, and anarchy. It provides an alternative to self-help and blood feuds. Sometimes it even makes important, historic decisions.
Some History
Let’s stand back and look at about a century’s worth of U.S. health policy in a few paragraphs.
The Preamble to the Constitution—the “mission statement” of the U.S. government—includes as one of its purposes “to promote the general welfare.” The Founders did not, of course, dream that “the general welfare” should include healthcare. After all, while lawyers were writing the Constitution physicians were applying poultices and bleeding sick people to bring the “four humors” into balance. Such was the state of the medical profession in the 18th century.
But scientific knowledge grew quickly after the Civil War, and medicine progressed due to the availability of anesthesia, recognition of germ theory, development of vaccines and antiseptic techniques, discovery of x-rays, improved nursing practices, and better standards for medical schools and hospitals. Thus it was that about a hundred years ago a recognizably “modern” health care system began to emerge. Doctors and hospitals were causes for hope. Better health care was possible. And better health care advanced the “general welfare” of the people.
In 1912, when Theodore Roosevelt ran as an independent presidential candidate, his platform supported various kinds of social reforms including workers’ compensation and health insurance. Roosevelt believed that “no country could be strong whose people were sick and poor,”[1] and his campaign marked the first time health care was considered a national policy issue. But Roosevelt lost the election to Woodrow Wilson, and health insurance then lay dormant as a political topic until TR’s cousin Franklin Delano Roosevelt and the New Deal came along a generation later.
The Social Security Act that passed Congress in 1935 included various programs familiar to us today including old-age assistance, aid to dependent children, and unemployment insurance. A plan for national health insurance was considered briefly, but the idea was shelved because it was not politically viable and would have jeopardized other aspects of the Social Security program that were more palatable to politicians. A few years later during WWII, when wage and price controls were in effect, employers added health coverage as an extra benefit in lieu of salary increases, so the need for national health insurance became less acute. (Incidentally, this is why for more than sixty years most Americans’ health insurance has been tied to their place of employment.)
In 1948 President Truman campaigned for reelection on a platform that included a national health insurance plan. Truman defeated Governor Thomas E. Dewey and the Democrats regained control of Congress, but they were not able to pass the health insurance legislation because Southern Democrats feared that federal involvement in health care might lead to desegregation of hospitals. (They might have been right.)
The next major healthcare reform, of course, was the enactment of Medicare and Medicaid in 1965, two programs that are now so much a part of the American fabric that their beneficiaries seem to view them as inalienable rights. It quickly became clear that Medicare’s cost-based reimbursement formula was a huge financial burden, so in the early 1970s the Nixon administration proposed prepaid plans (HMOs) and other cost-cutting measures, all of which had little effect on government expenditures. Finally—perhaps to distract attention from the Watergate scandal—Nixon proposed a national health insurance plan that would have provided comprehensive benefits for all Americans. One authority has written, “If the name on the administration’s plan had not been Nixon and had the time not been the year of Watergate, the United States might have had national health insurance in 1974.”[2] As it was, another generation would grow to adulthood before the time was right to try again.
That time, of course, was President Bill Clinton’s reform effort in 1993-94. His plan—sometimes derisively referred to as “HillaryCare” after First Lady Hillary Clinton who chaired the President’s task force—would have provided universal coverage by mandating insurance for everyone and setting up insurance cooperatives to help the poor obtain coverage. The effort barely got off the ground due to the complexity of its various provisions, the press of other important business (NAFTA, a budget battle, and “Whitewater,” for example), and heavy opposition from conservatives, libertarians, and the health insurance industry. Sound familiar?
Returning to Today
Now, fifteen years after Clinton’s efforts failed, President Obama and a Democratic-controlled Congress, have passed the most significant healthcare reform legislation since Medicare and Medicaid 45 years ago, the “Patient Protection and Affordable Care Act.” I have a summary description in which each of its many sections is reduced to one or two sentences. The summary alone comprises 53 single-spaced pages in a Word document, and the full bill is said to be more than two thousand pages of mind-numbing legislative language.
Among PPACA’s many objectives are these:
- extend coverage to 32 million uninsured Americans,
- ban certain unfair insurance company practices (such as denying coverage to people with pre-existing medical conditions),
- close the Medicare prescription drug “donut hole,”
- improve access to Medicaid,
- enhance the children’s health program,
- improve Medicare payment practices,
- improve health care workforce education,
- reduce the risk of fraud, and
PPACA will not meet all of these goals, of course, and it will have some negative, unintended consequences. (Most laws do; big laws
always do.) We won’t know what these problems are for some time because many of the important provisions won’t take effect until 2014 or later. But whenever the flaws and oversights and unintended consequences become apparent, they can be fixed. That is the nature of law: it responds to changing circumstances. At least we now have something “on the books” to work with.
Of course, Republicans are already talking about repeal, conservative activists are filing lawsuits, and some states are making plans for referendums to exempt themselves from PPACA’s requirements. Federal law trumps state laws, so the referendum idea is unlikely to succeed, and the lawsuits will take years to resolve. It will be interesting to see how all this plays out. One thing is certain: lawyers and consultants will do well in the meantime.
My Original Premise
So I return to my original premise: that with all its flaws, our democratic system of government does work, at least in the long run. Regardless of one’s feelings about Congress, the President, politicians of either party, politicians in general, or the health reform bill in particular, it cannot be gainsaid that last night’s action by the House of Representatives was important and historic.
It also cannot be denied that our system is Darwinian. Just as in nature where, given enough time, evolution works to improve the various species, so too does our form of government, given enough time, allow for trial and error and survival of the fittest ideas. Nearly two and a quarter centuries after the Preamble to the Constitution was written, and after a century of experimentation and the efforts of seven presidents, we have finally decided as a nation to “provide for the general welfare” in the realm of healthcare. We are the last developed country to do so, but we did it. And we did it without riots in the streets.
I am reminded of what a great philosopher of the 20th century once said:
"Americans can always be counted on to do the right thing ...
after they have exhausted all other possibilities."
--Winston Churchill
Notes:
1. Starr, The Social Transformation of American Medicine, p. 243.
2. Id. at 405.
3. CBS news has a good summary of what’s in the bill. They have a typo, however: “$1.2 billion” should read “$1.2 trillion” in the deficit paragraph.
See http://www.cbsnews.com/8301-503544_162-20000846-503544.html
