America’s health wars

The issue of healthcare has erupted on the American political scene. Upon entering the White House, Barack Obama proclaimed that, after rescuing the economy, reforming the US healthcare system was his top priority. So it was always clear that healthcare reform would be an important issue. Few, however, expected the heated and impassioned debate that Obama’s proposals have sparked.

The strongest images from recent weeks are of opponents of reform shouting down Democratic Party congressmen at ‘town hall’ meetings in their constituencies. Outside the meetings, signs with swastikas declared their opposition to ‘Nazis’ and, at one event, an effigy of a congressman was hung by a noose. Inside a meeting in Pennsylvania, Senator Arlen Specter was heckled by a woman shouting, ‘We don’t want this country to turn into Russia!’

When the TV news programmes are not showing such scenes, they have been debating the merits of former Republican presidential candidate Sarah Palin’s claim that the reform proposals would introduce ‘death panels’ – that is, boards that could deny care to the elderly on euthanasia grounds. Palin also added that the proposal would harm the handicapped, like her own son who has Down’s syndrome. Her message was picked up by more mainstream Republicans, such as Senator Charles Grassley, who for good measure also said that Senator Edward Kennedy, the grand old man of the Democratic party currently suffering from a brain tumour, would be left to die if he relied on the British National Health Service.

The Democratic National Committee (DNC) responded by saying ‘the right-wing extremist Republican base is back’ and is ‘organising angry mobs’. To try to regain the initiative, Obama has held his own town hall meetings from New Hampshire to Montana, and he looks like he is back on the election trail. The battle has also taken to the airwaves, with interest groups on all sides spending record amounts on TV advertisements. The Campaign Media Analysis Group says ‘we’re looking at one of the biggest public policy ad wars ever’ (1).

What’s led to this unexpected outburst? The country has not become full of healthcare enthusiasts, wanting to debate the finer points of policy. The over-the-top responses from both sides – from those yelling ‘granny killer’ to those raising fears of a Ku Klux Klan-style mob – show that this debate really has very little to do with healthcare per se.

The trouble with US healthcare

The US health system has serious problems and is in need of reform. The US spends far more than other developed countries on healthcare. According to the World Health Organization (WHO), the US spends $6,719 per person, compared with $2,815 in the UK, $3,420 in France and $3,673 in Canada. Yet life expectancy is higher in those three countries than in the US, and US healthcare results fall short by other yardsticks as well (2). Within the US itself, costs and outcomes vary widely by location (3).

Private health insurance premiums have risen by 78 per cent since 2001, while wages increased 19 per cent and general price inflation rose by 17 per cent, according to a 2007 study by the Kaiser Family Foundation (4). At the same time, the system leaves too many with inadequate coverage. In fact, some 48million people, about 15 per cent of the population, are without insurance coverage (5). The US ‘is the only wealthy, industrialised nation that does not ensure that all citizens have coverage’ (6).

The fact that the US system spends so much to produce outcomes that are no better, or even worse, than those in other countries leads many to argue that the US system is overly costly, wasteful and inefficient.

Obama’s proposals

Obama’s reforms seek to address these issues. They include: greater access to care for those currently un-insured; greater regulation of insurers to prevent situations, for example, where people purchase insurance only to find at a later date that something is not covered or are denied coverage due to a pre-existing condition; and cost-reduction measures in the system (7).

However, unlike the Clinton reforms in the 1990s, Obama’s proposals do not challenge the fundamentals of employer-based private insurance. Obama, unlike Clinton, will also not change the ‘fee for service’ reimbursement that gives doctors an incentive to order multiple tests and other services, which many claim is a major source of inefficiency in the system.

Because Obama’s proposals do not seek to overturn the private-sector foundation of the system, they have received unprecedented support from quarters most known for opposing reform in the past: doctors, drug companies and health insurers. During the 1990s, the pharmaceutical industry produced the ‘Harry and Louise’ TV commercial that was credited with sinking the Clinton reforms; ‘Harry and Louise’ are now back, but this time they are in favour of reform.

The US system, while primarily based on private insurance provided by employers, has for a long time had significant state input, from the government-operated Medicare (for over-65s) and Medicaid (for the poorest) to extensive regulations over the private health sector. This private-public mix is more generally recognised and accepted than in the past. In this environment, shouting ‘socialist’ or raging against ‘the government’ sounds very abstract and hollow.

An uncertain plan

One problem is that the administration’s proposals are not fully worked out, and this has hampered the debate, because people do not really have a finalised plan to evaluate. It seems that the president and his team believe that the Clinton approach was too top-down, and so they have let Congress take the lead with drafting the legislation. Currently, there are multiple bills in both houses. While there is a significant degree of overlap, some contentious issues, such as the so-called ‘public option’ (which would offer people the opportunity to purchase health insurance from the government), remain.

One of the main areas of confusion concerns cost reduction. It is clear that expansion of coverage will increase government expenditure, yet it is not evident how this will be paid for. Obama has tried to reassure people that their insurance plan will not change, and the state will not come between the patient and the doctor.

Yet, without hearing specifics, it is not unreasonable for people to suspect that a centralisation of control by the government will facilitate more rationing or ‘gatekeeping’ of care. Obama may demonise insurers today as the main villains for poor healthcare (including rationing care), but it is hard to see claims adjusters going away under a plan that aims to squeeze out unnecessary expense.

Republicans: searching for a cause

While Obama’s proposals are still to be finalised, they have received broad support. Meanwhile, the town hall protesters’ arguments are all over the place, and bear only tangential relation to specific health issues. They are often confused, too. More than one senior citizen got up in the town halls to both attack nationalisation and defend Medicare benefits. As one woman wrote to Obama: ‘I don’t want government healthcare. I don’t want you meddling in the private marketplace. And keep your hands off my Medicare.’ She was seemingly oblivious to the fact that Medicare is a 100 per cent government-run programme.

In the past, shouting ‘socialist’ was an effective rebuttal to any reform that involved greater government involvement. The US has long resisted a nationalised health system like those in the UK or Canada. In the post-war period, opposition from various interest groups was linked to Cold War anti-communism. Many liberal presidents failed to overcome such opposition, most notably Bill Clinton in the early 1990s. But things have changed. The Cold War is clearly over, and there is far less strident anti-government and pro-market sentiment (although it has not totally disappeared).

The fight this time is actually more one-sided than the town-hall rowdiness would suggest. In the ad wars, for instance, $24million is being spent by Obama plan supporters, versus $9million by opponents (with a further $24million in favour of overhaul, without backing a specific plan) (8).

The shrill tone of the protests is not a sign of strength, but of weakness. It reflects the disarray and marginalisation of Republicans. Since the election, they have been at sea, not knowing how to deal with Obama and the new political environment. It is noticeable how many of the protesters are older – the one group where there was not a majority for Obama in November’s election. The rise of Obama has coincided with a generational shift in American politics, and many older people are the most suspect about change.

At the same time, the fact that Palin and talk-radio host Rush Limbaugh are the public faces of the Republicans these days shows what kind of difficulty the party is in. Republican politicians have been uncertain as to how to respond to the town-hall protesters: most have sought to latch on opportunistically, but others are wary that they will be defined as unreasonable. The result is that Republicans in Congress are not offering a substantial alternative to the Obama reforms.

Echoes of the Culture War

Yet it would be wrong to dismiss the charged atmosphere around healthcare in the US as the work of a few Republican cranks. That’s certainly what the Democrats would have us believe, but their denunciations of the ‘mob’ have only dragged down the discussion further. It seems that whenever Obama and the Democrats stall, they fall back on Culture-War stereotypes. During the election campaign, they similarly claimed that Republicans were a ‘mob’ of Nazi-like thugs, unhinged nutjobs on the verge of assassination attempts (9).

Democrat leaders talk about the Republicans whipping up their base through exaggerations and fear-mongering, but that is what Democrats have been doing, too: they rely on raising the spectre of frothing-at-the-mouth right-wingers to cohere their own liberal base. Indeed, Democratic Party bureaucrats have arguably needed to resort to that fear-based approach given the apathetic response to the Obama plans by their own party supporters. During the election contest many argued that Obama was creating a new movement based on young volunteers that would endure beyond the election itself. But nothing like that has emerged since his victory; his supporters have remained mostly spectators. Obama’s Organizing for America, for instance, has had a low profile during the healthcare debate.

The Democrats’ ‘blame the mob’ response is problematic as it is a caricature of people who dissent, and thus it alienates a broader group than the tiny band of town hall protesters. It also, unintentionally, makes the protesters appear more principled; many have now taken to wearing ‘Proud Member of the Mob’ t-shirts. Democratic Speaker of the House Nancy Pelosi even referred to them as ‘unAmerican’. Demonising those who disagree is a patronising way to shut down debate, and turns off those who are not narrowly partisan.

Reform, but no trust

Polls show that while most Americans agree that the system needs to be reformed, they are also are uncertain about the Obama proposals (10). To the extent that the healthcare debate has been about the issue itself, Obama’s leave-it-to-Congress approach has not helped address such concerns. With so much uncertainty, the only conclusion is that people must trust the administration and its allies in Congress to sort things out.

That gets to the crux of what’s behind today’s bombastic debate – anxiety about change and a lack of trust. This sentiment is shared by Republicans, Democrats and independents alike; it just takes different expressions. The economic crisis, and the speed with which the government moved in to take over the banks, insurance companies and auto companies, has certainly contributed to the instability, but it is more than that. It is a sense that society is moving, and people do not have control over its direction.

On his latest town hall stump, Obama has returned to his election theme, saying that healthcare reform requires choosing hope over fear. But, as during the election, this involves hyping up the ‘fear’ of an unruly mob, and asking people to have ‘hope’ in something unspecific – and to the extent that you do learn some details, you find that is an incrementalism that is not going to bring much progress.

With a Democratic majority in Congress, Obama is likely to get legislation of some kind passed; getting strong public support is another thing altogether.

Sean Collins is a writer based in New York.

(1) Competing Ads on Health Plan Swamp Airwaves, New York Times, 16 August 2009

(2) World Health Statistics 2009, World Health Organisation

(3) 10 steps to better healthcare, Atul Gawande et al, New York Times, 13 August 2009

(4) Health insurance premiums rise 6.1 percent in 2007, less rapidly than in recent years but still faster than wages and inflation, Kaiser Family Foundation press release, 11 September 2007

(5) US Census Bureau, August 2008

(6) Insuring America’s Health: Principles and Recommendations, Institute of Medicine at the National Academies of Science, 14 January 2004

(7) As bombast escalates, a primer on the details of healthcare overhaul, New York Times, 10 August 2009

(8) Competing Ads on Health Plan Swamp Airwaves, New York Times, 16 August 2009

(9) See Republican rallies: the myth of a crazed mob, by Sean Collins, 18 October 2008

(10) What do we know about health reform?, CBS News, 16 August 2009; Poll: protests fuel opposition to health reform bills, Kaiser Health News, 13 August 2009