When I was 16, I was taken to the hospital by ambulance and placed immediately in an isolation unit whereupon a drip was inserted to my right forearm, just above the wrist. I had been ill, off and on, for the previous two years, causing me to miss then-important chunks of my school education. I spent some time delirious on the drip, with varying levels of awareness and wakefulness. I can vaguely remember peering without comprehension at a small TV screen that had been wheeled close to my bed. Somewhere in the fog was a beguiling nurse who was just doing her job. The emergency, I later learned, was that I had a virulent form of glandular fever (mononucleosis), which was causing my throat to close over, and I had lost 20 percent of my bodyweight. After some time — perhaps three days — I was taken off the drip but remained in isolation.
Bored, and doubtless with some pressing teenage matters to take care of, I duly raised from my sick bed, dressed, and walked out of the hospital to catch a bus for the 45-minute trip home. At least that is what I am told. I was still so sick I have no memory of leaving the hospital at all. It was only when I was in my late 20s that the topic came up in a family conversation. Everybody assumed I knew what I had done. Could I have been compelled to make this unconscious journey by the fear of the cost of an extended stay in the hospital? Perhaps it was the thought of the exorbitant expense of the ambulance ride a few days earlier? It was none of these things. It was simply teenage restiveness and the congenital belief that I know best. I was in the hospital in England. My ambulance ride was free, as were the drip and its fluids, the bed, the TV — all of my care would have been free had I remained in the hospital forever. When I returned to the hospital a few months later for a tonsillectomy, the whole thing was free. The United Kingdom is one of a vast majority of countries that has a free at-source healthcare system, a.k.a. universal healthcare. These countries are as diverse as Ghana and Germany, Croatia and China, India, Hong Kong, Botswana, South Africa, Israel, Sweden, and, yes, Canada. The list goes on. The United States of America is conspicuous by its absence.
The above is by way of a declaration an announcement that I have personal interest in the healthcare debate that has ebbed and flowed in this country for many years, though it was perhaps never more vehement than during the passage of Obamacare or The Patient Protection and Affordable Care Act. Still, it seems that healthcare remains a puzzle in search of a solution. Witness the thoroughgoing calamity of the attempts by the U.S. Senate to craft some form of legislation to “repeal and replace” Obamacare these past nine months. My interest is also somewhat at an academic level. I wrote my bachelor’s thesis on healthcare, at a point when — perhaps ironically — the U.K. healthcare system was seen as being in danger of selling out its founding principles of “meeting the needs of everyone; free at the point of need; and treatment based on clinical need not ability to pay.”
My sense is that, in spite of outward appearance, the U.S. healthcare system is headed in the right direction — toward universal healthcare. No, I’m not kidding.
Health coverage grew in extent and range through World War II, via the growth of the labor movement and with the introduction of the federal tax code in 1954, leading to more widely available employer-provided healthcare coverage. Post-war Britain passed a series of laws in 1945 to ensure that returning soldiers and their families would be taken care of through access to free healthcare and financial aid. This appears to be the point in time when the United States diverged from the mainstream of liberal economic orthodoxy, choosing an individualistic rather than a collective path that would come to be framed by President Kennedy as the “rising tide [that] lifts all boats.”
When Medicare was introduced in 1965, its aim was to offer older Americans coverage similar to that available to the working population. The 1980s saw the development of managed care, a system in which patients agree to visit certain doctors and hospitals that are prescribed by a managing company. This greatly increased price competition among insurance providers. This “forced revolution” led many people (consumers) to feel they were losing control of their healthcare, resulting in a state-by-state backlash. Lawmakers served up a slew of legislation through the mid to late 1990s. This came around the same time as the newly minted president and first lady — the Clintons — failed to reform the healthcare system by providing every U.S. citizen a “healthcare security card” (similar, for example, to the national insurance card every U.K. person holds). The next several years saw Americans asked to pay premiums spiraling ever upward along with out-of-pocket expenses. In this context came “hope and change” through Obamacare. Mark March 23, 2010, as the beginning of the end for private health insurance. The corollary of which is the beginning of universal healthcare.
Obamacare’s main provisions came in to force in 2014. Within two years, the number of people without coverage had about halved. It is estimated that between 20 million and 24 million additional people gained coverage during the first two years of Obamacare. Let us consider this in human terms: As many as 24 million Americans who had no access to healthcare in early 2014 were cured of this ill by 2016 as a result Obamacare. That’s 24 million Americans who went to bed at night in 2014 hoping, some praying, that they did not become ill or have an accident at work and that their loved ones remained healthy who could sleep easy in 2016. Hell, they might have even treated themselves to some routine wellness checks or even a trip to the dentist. Some may even have gotten the eyeglasses they had needed for years. We live to dream.
The increased coverage was the result of both an expansion of Medicaid eligibility and major changes to the individual insurance markets. On both fronts, increased government spending was funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage (Part C, offered by private providers approved by Medicare). While retaining the existing structure of health insurance — Medicare, Medicaid, and the employer market — Obamacare radically altered the individual markets. Gone were the penalties for pre-existing conditions, most notably. With individuals now mandated to take out health insurance, Obamacare provides subsidies for those households between 100-400 percent of the federal poverty line, attempting to make healthcare affordable for all.
The ugly truth of the current healthcare system is that it leaves a significant minority of people without coverage. In 2010, 28.1 percent of Tarrant County residents were without healthcare. That is a stunning 318,358 people. People. Your neighbor, coworker, friend, mother. These are actual human beings, not just statistics on a page. Of the more than one in four without healthcare, 75,824 of them were children. These numbers have to be shocking. Something had to be done, right? By 2014, the first year under the provisions of the ACA, the same measures saw 290,716, or 24.2 percent, without healthcare, of which 56,738 were children. These numbers are still far too high, but on the upside, nearly 28,000 of our fellow Tarrant County residents slept at night knowing they had healthcare.
For some answers, I reached out to numerous friends and colleagues. To a man and woman, they told me that their every healthcare thought and decision has a financial basis. White collar, college-educated professionals in the richest country on the planet all told me that they worry about the cost of healthcare and, moreover, consider cost before making healthcare-related decisions. These considerations begin with the most simple question of whether or not to visit a doctor’s office. A thankfully small number among my friends and colleagues had tales to tell of ongoing health issue and their impact on the day-to-day.
A friend of mine has been diabetic since age 9, relying on healthcare and access to it in every situation of their life. “I’ve gone to grad school and accepted jobs mostly for my career but also partly to have the peace of mind of continued healthcare coverage,” they said. The treatment of diabetes continues to develop with ever-smarter technology to manage the condition. Though to live “a healthier life with tighter control of your blood sugar, you have to pay a hefty price tag.”
Our friend wears a $7,000 insulin pump device. Thanks to an extensive, expensive employer healthcare plan, the copay is $10. We should pause here to consider how fortunate one is to have healthcare, then consider the price tag without it. Someone without insurance or even with a low-level policy does not have access to the same treatment as our friend, who concisely captures the dilemma. “Every time I open a medical equipment bill or pay for my insulin at the pharmacy, I cannot fathom dealing with this illness without insurance,” they said.
And the idea of losing their policy looms over them and shapes the decisions they continue to make in life: “It’s an added stress in addition to a lifelong disease.” Let this sink in.
Much of the opposition to the changes wrought by Obamacare has received better coverage and more airtime and column inches than the improvements wrought by the Act itself. As such, I won’t rehash these arguments or give them further column inches even in refutation. Let us instead deal with the reality of where we are today, as Texans, in terms of healthcare coverage.
In looking at the healthcare landscape pertaining to Texas and, more specifically, to North Texas, I need to point out the spectacular lack of input I received upon reaching out to a number of our elected offices and to political parties and entities. I am sad to say that principal among the non-contributors was Mayor Betsy Price, who led me on a dance for 22 days before declaring that she couldn’t meet my request for information about the extent of healthcare coverage in the city or furnish me with a comment. I also reached out to the Tarrant County Democrats, the Texas Democrats, Tarrant County Public Health, and Fort Worth City Councilmember Anne Zadeh, all of whom failed to respond to email. One shining example of timely response and willingness to engage was Texas Representative and 2018 Senate candidate Beto O’Rourke.
A former musician-turned-politician, O’Rourke wears his progressive heart on his carefully pressed shirtsleeve. He is keen to stress the benefits of building on the gains made through Obamacare. “We are literally seeing lives saved,” he said.
In every town he visits, he said people stop him in the street to thank Obamacare for their very breath. The main weakness in the system, according to the would-be Senator, revolves around the failure to expand Medicare, which means, “We’re seeing too many Texans suffering, too many dying. We’re doing everything we can to expand Medicaid.”
O’Rourke sees the future as “true universal healthcare,” adding that it’s the only way to ensure everyone gets to see a doctor when they need to. He also sees universal as the “only way to reduce total healthcare spending as we deliver that healthcare far more efficiently and effectively.”
In the first few months after moving to Fort Worth, I made a habit of Skype-ing my parents back in England. Every Sunday morning I would dutifully call up, anticipating the weekly view of my dad’s wildly unfettered eyebrows and the top of my mom’s head. I would wonder what particular perfectly set style and color she would be sporting each time I called. After the soon traditional explanation from me about being on video call, and their rollercoaster ride wrestling with “the camera,” which afforded me quick-fire views of ceiling, drapes, floor, couch, then faces, we would settle in for a “catch up.” One Sunday they called me. They were using voice call, not video, which seemed a little odd, but I settled quickly on the notion that they didn’t want to wrestle with “the bloody thing” or that my mom’s hair, for once, was not set. It took less than five minutes of preliminary chat for my mom to inform me that she had breast cancer, her voice tremulous as she assured me that “everything is fine” and “I’m not going to die.”
On October 16, 2017, mom was given the all-clear by her cancer specialist. No more cancer. In the intervening three years, we did not video call each other once. The voice calls remained a mostly weekly ritual. At first I supposed that my mom was doing that stoical thing of not wanting me to see here deterioration through rounds of drugs and torture of chemotherapy. She narrowly avoided having to wear a wig, which would have been, to her, the ultimate ignominy. The diagnosis, treatment, and the all-clear cost nothing. That is to say, my mom paid $0. Had she needed a wig, its selection and fitting would have been free of charge also. From that initial devastating voice call, I could rest assured on one thing: that my parents didn’t have to worry about how they would pay to save my mom’s life. If England had a U.S.-style healthcare system, the outcome would have been very different.
I spoke with someone who experienced cancer as a teenager here in Texas. Her experience was markedly different from my mom’s. For a little context, this colleague turned 27 in December 2013. This is salient because during this time, the rules of the Affordable Care Act were still being implemented. She was able to stay on parental health insurance through the age of 26, but pre-existing conditions within the previous five or six years could still hinder a person from getting insurance. If this looks a lot like a precursor to a textbook example of how penalizing people with pre-existing conditions is essentially an immoral money grab, read on. On turning 27, she started searching for affordable health coverage on the open market.
“I found out I was ineligible because of my previous cancer treatments,” she said. “My treatment for cancer was in 2005.”
Insurance companies penalized this cancer survivor for assiduously attending annual check-ups, prescribed by her doctor. To add financial insult, “I asked the insurance associate if I had been reckless and never gone for a single check up after chemotherapy, they would cover me? ‘Yes’ was the answer.”
Because she followed doctor’s advice, there was no insurance coverage available. As a result, “That year I was forced to get coverage through the Texas risk pool. My premium tripled in price.”
There are other ways to approach the provision of healthcare. The principal alternatives to the status quo on healthcare are a single payer system or universal coverage, two subtly different options, neither of which represents socialism. (An acquaintance actually had the gall to say that that terminally ill English newborn in the news wasn’t getting the care he required because of universal healthcare. Spitting “arrant nonsense” was all I could do to refrain from pouring milk in his Earl Grey, thereby adulterating the finest of teas.)
Universal healthcare is a system in which every individual has health coverage, such as in Canada and the U.K. In 2015, the U.S. Census Bureau found 29 million Americans without health insurance coverage. This was down from 46.6 million 10 years earlier. Obamacare was responsible, in large part, for this staggering improvement.
In Canada, there are no uninsured Canadian citizens. Zero. None. Every Canadian is covered. See any socialism over our northern border? Me neither. What you see is universal healthcare coverage in a thriving free-market democracy.
The Republican-controlled Senate and White House seem determined to lay waste to Obamacare. This is evident through a series of barely thought out bills brought before the Senate only to be shot down by a slim majority each time. They will be back with something that attempts to “repeal and replace” Obamacare. The trouble for the neophyte POTUS and his acolytes is that the genie is out of the bottle. Legislators in California and New York realize this.
California’s recent Senate Bill 562 was a bare bones bill for now that outlined a single-payer system dubbed “Medicare for all.” The bill passed through their state Senate earlier this year only to be shot down by the assembly due to a lack of policy specifics. Be assured that the bill will return in the near future. While the task of getting to the end zone is met with many a would-be tackler, the momentum in California is with the team possessing the ball.
In May, New York’s State Assembly passed the New York Health Act, a universal health care bill that would provide universal care to all New Yorkers. That means healthcare without premiums, co-pays, or deductibles and with no limited provider networks. New York has been here before when it passed a universal healthcare provision in 1992 only for it to die on the road to Washington. The current act, by independent measure, will cover 98 percent of New Yorkers and save the state $70 billion, principally from cutting administrative costs.
Beto O’Rourke sees some credence in the view that these two states can help drive change, reflecting that “as states wait for the federal government to take the lead, they are just moving on their own, which may force the hand of federal government.”
He hopes for the day when Texas could be part of that, to proactively offer a better alternative.
In undertaking research for this article I have encountered a lot of frankly embarrassing tosh, both written and uttered, to explain why the United States is so out of whack with the world in not embracing universal healthcare. Primary among the arguments is that America is unique in its culture and society — the self-delusion that forms a key part of American exceptionalism. This is the cultural misdirection that has enabled this nation to thrive and surge above others, in many regards, yet it limits us greatly, too. I have read and heard that America is a uniquely individualistic society, a place where people would rather fend for themselves than trust the government to run their affairs. Fair enough. Then why is the United States currently ranked second of 140 countries on the World Giving Index (an international index of charitable giving)? It is worth noting that we were No. 1 in 2013 and 2014.
America is ready and able to adopt a system of universal health coverage. I see the majority of people being willing, too. Research and experience lead me to believe that the United States will join the international fold by formally (that is, “legislatively”) introducing universal healthcare nationally no later that 2030. In so doing, there will be no descent into a socialist dystopia. There will be status quo ante, except that you won’t die simply because you cannot afford an ambulance ride, hospital stay, or medication.
Thinking of the likelihood of a sea change, O’Rourke poses and answers the key question, “Will Texas get to universal healthcare within 10 years? I sure hope so.”l
I have always had a problem the idea that the lack health insurance is the same as the lack of healthcare. The falsehood was used as the driving argument for the ACA. It is as if we forgot about John Peter Smith Hospital, the many public health clinics, and vaccination clinics across our county. You may not get the healthcare you want, but nobody was left to die by the side of the road. Our public health system was not the most efficient, but we did (and do) have public healthcare in Tarrant County (not to mention Medicaid, medicare, and the VA).
I get very worried when we refer to healthcare as a “right”. Healthcare relies on someone’s labor (nurses, doctors, aides, pharmacists, researchers etc). Nobody has a “right” to someone else’s labor in a free society. As a democracy, we may decide that it is good public policy to use our tax revenue to pay for healthcare, but it is not a right. Rights are something you inherently own, not that you take from someone else.