HEALTH CARE/Joan Retsinas

Roots: Digging into our Souls

Every gardener searches for roots. In fields overrun with underbrush, the gardener must clear away the debris to isolate the roots of trees.

Our health system is not so different. The terms – risk-based pools, eligibility thresholds, COBRA, deductibles, preferred provider networks– litter the field. An onlooker sees only a conflicting mishmash of rules. But as any gardener knows, there are roots, even though the mishmash of words obscures them.

Digging into the lexical underbrush, two roots emerge. Consider them key questions that undergird our confusing approach to health in this country – a window into our collective soul.

First, do we value “health?” The answer is clear: we extol it. And we revere technology. We have “precision medicine,” where we harness genetic wisdom to customize treatments. We have “biologic drugs,” manufactured in living organisms. Our diagnostic imagery evokes Star Trek; our MRI machines look like space capsules. If our hearts, our valves, our knees, our hips deteriorate, we can replace them with niftier models. If we are fat, we can rush for bariatric surgery. For women, we can improve fertility; for men, we can improve potency. We perform surgical feats on fetuses; we stall octogenarians en route to the Styx. From whooping cough to polio, we have overcome the diseases that bedeviled our grandparents.

Crucially, insurers, public and private, have for the most part paid for these technological marvels. Insurers may balk at paying for smoking-cessation programs, or car seats for children. But they will pay for expensive procedures.

The second question – the root, if you will - of our health “system” in this country – is the thorny one. Who will get this wondrous life-enhancing panoply of goodies? Western European countries made a simple decision: every citizen, regardless of income, province, ethnicity, race, or health status, was entitled to whatever health services the country offered.. Admittedly, those countries have not embraced technology with our gusto; and some Europeans buy enhanced access, or shorter wait times for procedures. But in general Western European countries consider “health” a right.

We don’t. In our marketplace of services, Americans line up in different queues, depending on a hodgepodge of distinctions.

Before the Civil Rights victories, race was a key demarcation: African Americans had less access to fewer services.

And before the Affordable Care Act, health status was another key demarcation. Sick people faced periods where insurers would not cover “pre-existing” conditions. Ex-employees with disabilities who wanted coverage under COBRA had to pay far higher premiums than their healthy counterparts. Indeed, some insurers rejected ill applicants as “uninsurable.”

But today other lines remain. Working status, for instance, is central. Until 1965, we expected most Americans to get health insurance via their workplaces. In 1965 we revisited that blithe assumption. After all, retirees, people with severe disabilities, and poor mothers with children were not working, were not likely to work. So Congress passed Medicare and Medicaid to cover those non-workers. Yet with Medicaid cleavages remain: a poor person in Minnesota was always more likely to have coverage, and better coverage, than his counterpart in Alabama. Indeed, under the Affordable Care Act, some states have expanded Medicaid to enroll more people; others haven’t, in spite of generous federal incentives. As for people not connected to insurance via work – the self-employed, the part-timers, the seasonal staff, the unemployed – they stand in a long line. If they can afford to buy insurance on the private marketplace, they veer easily into another line; and, presto, they leave with insurance (though their very expensive policy may have gaps). But if, like most Americans, they cannot pay the tab, they go into a “subsidy” line. They need one. They cannot afford the cheapest, most minimal policy. And the Affordable Care Act provides for subsidies, but their chances of getting a sufficient subsidy depends on their state, as well as on the Supreme Court’s ruling.

Finally, the addicts, criminals (petty and major), ex-convicts, the downtrodden, the illiterates – the ones on the margins of society — line up. Do they get hip replacements? Precision medicine? Insulin? As a people, Americans are considered generous. De Tocqueville marveled at our sense of community. But we reach out to people we deem “deserving.” If health care is not a right of citizenship, do we offer it to people we consider “unworthy”? Consider COBRA. Initially the law required employers to let “terminated” employees buy health insurance at the group rate; but employers didn’t need to offer COBRA to employees fired with cause.

So in this marketplace we separate into queues. Americans serving in the military get healthcare, as do wounded veterans. But veterans who weren’t wounded go on a waiting list for Veterans Services. We offer care to legal immigrants, not to illegal ones, even though they may belong to the same family. We may make “co-payments” so high that we freeze out families. We structure government insurance so that where-you-live determines your access. We let some Americans forgo insurance: if they can’t queue up in the correct line, we let them languish.

Beneath the battles over the Affordable Care Act lies the fundamental question: Who gets the wondrous props to health that we have created?

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

From The Progressive Populist, April 15, 2015

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