HEALTH CARE/Joan Retsinas

District 9 for the Uninsured

In another century, philosophers will ponder why well-insured, ostensibly well-intentioned Americans isolated 47 million of their fellow citizens in a health care equivalent of District 9. What moral code buttressed this isolation?

The uninsured shared no racial, religious, or ethnic commonality. Their work status mirrored that of the population: they worked full-time, part-time, were self-employed, were contract workers. Some didn’t work. Some were wealthy (but not wealthy enough to buy insurance); some were middle-class; some, poor. Some were sick; others, healthy. Immigrants as well as descendants of pioneers fell into the mega-category. No mark of Cain distinguished them from the rest of the population – except for age. Everybody in District 9 was younger than 65.

What the denizens shared was isolation. The United States had astounding medical facilities, full of brave new world gadgetry, overseen by highly trained physicians. A pharmacopoeia of drugs could alleviate symptoms, as well as extend life. But the uninsured could not easily enter that world. Even the country’s poorly-funded public-health clinics and hospitals only grudgingly accepted patients without insurance. Accountants considered such patients “bad debt.” So the uninsured visited hospital emergency rooms if they got desperate; otherwise, they hoped that whatever ailed them would pass. While some lived in the District temporarily, many stayed for years. Indeed, anybody who exited District 9 with a documented malady entered an insurance limbo, carrying the stigma of a “pre-existing condition.” Private insurers would exclude coverage for that malady for up to one year.

From 2000 to 2009 the cadre of the uninsured grew as once-solvent companies (state and local governments too) handed out pink slips, as other companies raised premiums beyond the wallets of employees, as still other companies dropped insurance.

The denizens of this District 9 were the neighbors, colleagues, and family members of Americans outside the District. Yet those insured Americans blocked any reform that would extend insurance to everybody. Even some seniors, happily enrolled in Medicare, didn’t want to extend Medicare to anybody else.

Twenty-second century historians who ponder our ethical mores will sift through the explanations of the time. There were the economic explanations: the private insurers who benefited from the status quo lobbied to block any change that might decrease their revenue. Those insurers riled the masses with the specter of government-supported euthanasia, creeping socialism, and soaring taxes.

Yet the cooler heads of the time pointed out the myths behind those fears. The government did not support euthanasia (in fact, it had required hospitals and nursing homes to discuss “advance directives” with patients for a decade previously). The government had already stepped in to bail out banks, insurance companies, and the once-mighty auto manufacturers (two of the Big Three — Chrysler and General Motors- had declared bankruptcy). Besides, Uncle Sam already insured everybody aged 65 and over, everybody permanently disabled, everybody in the Armed Services; and the President assured constituents that no plan would force anybody to switch insurers (since many Americans were disgruntled at the fine-print caveats embedded in the contracts from their for-profit insurers, many people were likely to switch). As for taxes, the cooler heads pointed out ad nauseum that the country was spending 17% of GDP on health care, that a major chunk of that was going to administration, that costly visits to emergency rooms drove up the total tab, and that our current system was growing unaffordable, as annual premiums for family policies reached $15,000 (assuming all members were healthy).

Even as cooler heads dispelled the myths, the town hall protests continued.

Ethicists settled on the hypothesis of selfishness. The well-insured Americans — including a lot of Medicare recipients - feared that any extension of coverage would dilute their coverage. Medicare offered optimum coverage; polls showed 92% of enrollees satisfied. Medicare recipients feared that if Uncle Sam enlarged the “insurance” pie to cover another 47 million people, he would inevitably pare the slice given to the aged and disabled — the cadre so used to government insurance that when they screamed against socialism they didn’t realize that that was what they had. So even though every day the well-insured bumped into the uninsured, they still kept them in District 9. Ironically, ethicists had labeled young Americans early in the 21st century as the “me” generation. But their elders were just as egocentric.

Eventually I suspect that ethicists will have a new quandary: Why was there ever a District 9? Just as in the middle of the twentieth century Uncle Sam tore down the country’s racial District 9, opening voting booths, restaurants, housing, and schools to people once segregated into visible as well as virtual ghettoes, so too the country may one day give all Americans access to its wondrous health care facilities. Perhaps the best explanation: the electorate will find compassion.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, October 1, 2009

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