I write this inaugural diary as a public health researcher, and a strong Obama supporter. This is my attempt to explain what I value in health reform, and why I am both hopeful and frustrated by the current debate.
It is easy for a health policy researcher to despise the practicalities of a presidential campaign. Health care and public health are huge, complex, and troubled enterprises that touch every interest group in America. Each candidate must speak clearly and substantively about these the challenges facing health care. Yet the candidates cannot become enmeshed in many of the complexities we want to honor as clinicians and researchers. Meanwhile, health care is just one piece of a tough, important presidential campaign.
Most citizens (with the exception of most Kos readers) are equally uninterested in the fine print. They listen to us debate arcana of electronic medical records, reinsurance, risk adjustment, and the rest. They watch each candidate, and they rightly wonder: Which of these accomplished and privileged people understands the challenges I face? Who will address my interests and values as a patient, a caregiver, and, for many, as a health care provider?
I will not systematically distinguish the Obama plan from those presented by Senator Clinton and Senator Edwards. The Kaiser Family Foundation, Helenann, and others on this website have already performed this task. There are certainly real differences. Yet each candidate’s plan is a huge improvement over current practice. Each is vastly superior to what Republicans propose. Each is the opening bid within an impossible complicated legislative process. Whoever ascends to the presidency will need to accept many changes and compromises to navigate health reform through a legislative process specifically designed to thwart large changes. I will therefore avoid a detailed dissection of the substantive differences in three broadly similar Democratic plans.
Each plan reflects a political judgment that a national single-payer plan, though in many ways desirable, is not politically feasible at this time. Each reflects the principle that individuals should not face discrimination based on prior illness or injury. Each reflects the judgment that a system based on private health insurance, if it is to survive with any effectiveness or public legitimacy, requires much more careful oversight and intervention than it currently receives. As the annual cost of family coverage exceeds $15,000 in many places, each plan reflects the reality that millions of working families require financial help in purchasing health insurance coverage. I am heartened by the similarity across the plans. It suggests that Democrats are ready to govern.
Much of the primary debate has narrowly focused on one issue: whether to impose an individual mandate requiring adults to purchase health insurance coverage. I suspect that most voters agree with Senator Obama's proposal to make coverage affordable before taking this step. Because individual mandates raise intricate political and administrative tradeoffs, policy wonks can be found on both sides of this debate. I myself am much more concerned about other issues. The severely disadvantaged people who provide the focus of my work are uninsured because they cannot afford coverage. For them, the mandate issue is beside the point.
There are many economic and administrative arguments for health reform that are rooted in correcting the inefficiencies and stupidities of the current system. I think the best arguments are simpler. We are spending $2.1 trillion. Yet we treat many people indecently. People do not receive needed care because they cannot afford it. People lose homes because they become seriously ill. People can’t buy health insurance or cannot change jobs because they have a serious illness. In one rich irony among many, increasing numbers of healthcare workers are themselves uninsured. We can do better than that.
Both the candidates and the public would benefit if our national conversation moved past this mechanical matter to see the human faces on both sides of the examining room table: the patients who struggle to access needed services, and the people who struggle to provide proper care in an increasingly dysfunctional healthcare delivery and financing system.
Senator Obama recognizes these faces. So--for that matter--does Michelle Obama, a distinguished health care leader in her own right. Senator Obama began his political career pounding the pavement in south Chicago, in neighborhoods where public health problems are most glaring, and where hundreds of thousands of people lack access to needed care.
In the state legislature, first as an individual legislator, then as chairman of the Health and Human Services Committee, he confronted the challenges of fixing health care in a large and dysfunctional state. He made real accomplishments while he was there. He successfully reached out to Republicans and moderates to assemble working majorities for progressive policies when others thought this was impossible. He has inspired African-Americans and Latinos in Chicago, but also working-class whites in Cairo, Illinois who might never have supported a person of color before.
Senator Clinton, for her part, has proposed a good health plan. She argues that her policy expertise and legislative experience make her the most effective leader of health reform. Channeling Tip O’Neill, she argues: "You campaign with poetry, but you govern with prose." She claims the mantle of Lyndon Johnson, whose legislative mastery was essential for the passage of Medicare, Medicaid, and civil rights legislation.
Senator Edwards has also proposed a good health plan, and also claims parallels to the great liberal heroes of old. Edwards adopts an angry populism and promises to openly confront the pharmaceutical industry and other vested interests. In a recent blog, Professor Katherine Newman exemplified the populist perspective of many Edwards supporters. She states that Senator Edwards feels in his gut for the little guy, and that his personal story will steel him to fight when other Democrats would go soft. She says: "[W]e want FDR or LBJ in the White House. We don't want someone who will compromise or put a finger up to see which way the wind is blowing."
In my view, Senator Obama has the much better case. In the first place, his poetry seems more impressive than Senator Clinton’s (or Senator Edward’s) prose. Senator Clinton has been a knowledgeable junior Senator. She has no record of legislative mastery comparable to Johnson’s. She also starts with the great disadvantage that she attracts unique antipathy among moderate and conservative voters. She provides a unique focal point for conservatives to mobilize against Democratic candidates and liberal policy proposals. This is not right or fair. It is the way things are. That is also why Republicans openly celebrated when Senator Clinton won an upset New Hampshire victory.
John Edwards, for his part, passed quickly across the stage during his Senate years, leaving a conspicuously light footprint before his presidential run.
Most important, FDR and LBJ won the victories they did because they enjoyed huge congressional majorities at critical moments in American history. They could therefore prevail in a congressional system specifically designed to thwart large reforms. Both men were notorious compromisers and deal-makers when they lacked such majorities.
The next president will enjoy no such massive mandate. This person might well come into office with a wafer-thin majority. Our next president will therefore need moderate and independent allies. One might bluster about steamrolling and special interests. But then so did Hillary Clinton years ago, when her minions clumsily alienated key senators such as Daniel Patrick Moynihan, whom they desperately needed for health care reform. Democrats understandably hunger for a street fighter. Yet the ability to nurture broad political coalitions is more valuable than fiery rhetoric in enacting social change.
Senator Obama has these skills. A recent article by the New Republic’s Jonathan Cohn, one of the nation’s leading health journalists, describes Obama’s successful efforts to improve health care in Illinois. By common account, Obama showed a "talent to achieve consensus on a good compromise and then push it through. Doing hard bargaining with health insurers and others,
Obama was able to fight for what he and the reformers thought mattered most: bringing insurance to a great many more people. And they won, prevailing over resistant conservatives/ "He could not be accused of partisan aggression, [says John Bouman, a poverty advocate], but he got his way."
As a campaign volunteer, I have spoken to many Iowa, South Carolina, and Nevada voters. A surprising number identify themselves as Republican or Independent, yet express great interest in Obama. Yesterday, a strong Romney supporter asked me whether Senator Obama really pledges the flag and whether he is Christian. Then she surprised me: "I will be seriously looking at Obama in November." I don’t hear that about other Democratic candidates.
These things matter, because health reform is more crucial today than it ever has been. The human costs of our current health system grow every year. Urban health care systems are being crushed under the weight of 47 million uninsured people. My city includes large numbers of uninsured people, and a comparable number of Medicaid recipients on whom providers lose money given meager reimbursement.
The problem was never that we had some uninsured people. Nor was the large number of Medicaid patients inherently troubling, though the state had always provided low and late reimbursements for costly services. We have always had uninsured people: the homeless, undocumented immigrants, low-wage workers who took a chance. The problem is now is simple: We have too many of these patients. The old ways public and private providers navigated these issues don’t work anymore.
Our major academic medical centers have taken defensive measures. They assume a protective crouch to reduce their exposure to financially undesirable patients. Within walking distance of my office, residents of embattled neighborhoods experience remarkable mortality rates from HIV/AIDS, diabetes, pediatric and adult obesity, heroin overdose, and traumatic injury. Our university hospital is increasingly irrelevant to these public health concerns. Like many peers, it seeks a niche serving well-insured patients willing to pay a premium for high-tech services, as well as specific groups of other patients that fit particular teaching and research missions. Areas such as trauma care, psychiatry and substance abuse services, infectious disease, adult emergency medicine, and primary care are central to any reasonable account of our city’s public health needs. They are also decidedly peripheral to the competition for lucrative cardiac and cancer patients and low-risk insured ob/gyn services that dominate the economics of inpatient care.
While academic medical centers erect higher barriers, public hospitals and private charity providers face even greater burdens. Many hemorrhage money. The resulting problems are most severe at the public and nonprofit hospitals that have traditionally served poor people. Great institutions, such as Atlanta’s Grady Memorial Hospital, teeter on the edge of bankruptcy. County health systems are enduring punishing budget cuts and demoralizing layoffs. Some of the bleed reflects mismanagement. Yet the underlying wound reflects ever-growing costs to care for an ever-growing population of uninsured or underinsured patients.
These trends impose the most profound human costs on low-income patients, but the human costs are real for the rest of us, too. I am a well-paid professional. That didn’t spare my family from waiting ten hours in a crowded emergency department (ED) waiting to receive care. In countless ways, we all receive less efficient, lower-quality, and less dignified care than we have a right to expect.
Less tangibly, we all bear witness to avoidable suffering. Five feet away from us in that interminable ED visit, my young daughters watched a woman groan in visible pain for several hours before she was seen. We have gotten used to many things that should appall us. Not long ago, I dropped my child at dance class and sat in a diner for a cup of coffee. Taped to the door was a sign hawking raffle tickets to help pay for someone’s cancer care. This is now part of life in a rather middle-class community.
The human costs affect the men and women who work hard every day to provide health care under increasingly difficult conditions. It is demoralizing to turn patients away. It is demoralizing to know that your cardiac patient may go bankrupt because she is being harassed by your own hospital over a bill. It is demoralizing to spend countless hours fighting with multiple third-party payers before one can provide basic treatment. It is demoralizing to rush through a primary care exam because reimbursements only justify a 15-minute visit. It is demoralizing to lack the resources and organization to provide proper care. The people who work in health care--doctors and nurses, but also many others from the administrators and social workers to the licensed practical nurses and orderlies—take pride in their work, I have heard countless colleagues say with real sadness that they can’t do the job they were trained to do, or that they can’t care for people as well as they know they should.
The deterioration of emergency care is one obvious casualty of our fraying urban safety net. Given the times in which we live, homeland security experts recommend increased emergency care surge capacity in case of a natural or intentional mass casualty event. Yet many EDs have closed or are in financial trouble. Over the past decade, ED visits have increased, while the number of emergency departments has declined by almost 40 percent. Median wait times have grown. Almost all level 1 trauma centers operate at or above capacity. Practices such as ambulance diversion and extended "boarding" of ED patients in hospital hallways, once anomalous, are now commonplace.
Many commentators attribute crowding and delay to the bad behavior of patients who make inappropriate or avoidable use of ED services. I would not deny that ED crowding reflects a shortage of primary care and often suboptimal patterns of health care use by patients. Yet too much of this conversation takes for granted many troubling features of our current financing and care delivery system.
Health services researchers are coming to realize that the concept of "inappropriate" use is more slippery than commonly assumed. Emergency departments are a unique resource to find and serve people in great need. EDs may be the only places people know they can go, 24 hours per day, 365 days per year, and reasonable expect to find a trained professional to address their needs.
Moreover, the real nightmare facing many hospitals that motivates ED closure does not arise from inappropriate use. It arises from thousands of all-to-appropriate visits by uninsured or underinsured patients who require costly services and may require hospitalization. Under a different health care financing and delivery system, we would be less concerned about inappropriate ED use. We would provide better options outside the ED. EDs would have more resources to provide care. And hospitals would not regard EDs as the chink in their armor through which they are forced to admit unprofitable patients.
Less tangibly, the challenge of basic safety-net care is displacing other investments required to sustain public health. In Chicago, more African-American working-age men die from heroin overdose than from automobile accidents. Meanwhile, 600 heroin users languish on waiting lists for methadone treatment. Critical public health services in such areas as HIV prevention and correctional care face similar strains.
Our federal public health effort has also been deeply damaged during the Bush years. Despite huge increases in overall medical care spending, key public health agencies have been cut. Adjusting for inflation, HIV prevention efforts at the Centers for Disease Control and prevention have declined by 19 percent over five years. A recent survey reports that only 40 percent of CDC employees believe that top managers maintain high standards of honesty and integrity. Five former CDC directors—from both Democratic and Republican administrations—recently condemned expressed concern about serious "morale problems and questions of scientific integrity" at this once-proud agency.
In short, our medical and public health system is a mess. It won’t be fixed until we choose a Democrat who can actually win the presidency, and who can then assemble a working majority to get things done.
Senator Obama's intellect and personal presence, his efforts to build broad coalitions and to reach independent voters make me more excited about any Democrat since, well, Bill Clinton in 1992. No one who reads Senator Obama’s policy proposals or his two books can doubt that he is quite progressive. That is why Republicans fear him. That is why I am increasingly convinced that he will make a fine president.