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WHAT does broccoli have to do with the principle of universal access to health care?
Well, if you’ve been following the legal arguments over US President Barack Obama’s proposed health care reforms, apparently quite a lot.
In a country where an estimated 50 million citizens have no health insurance, the reforms are designed to provide universal cover by requiring most Americans to purchase insurance or face a financial penalty.
As part of the package, insurers would be prohibited from rejecting or imposing higher premiums on those with pre-existing conditions.
From an Australian perspective, it all sounds kind of … sensible. But nothing illuminates the differences between our two nations more clearly than a debate over the role of government in people’s lives.
And that’s where the broccoli comes in.
The “Obamacare” reforms are facing a constitutional challenge by 26 states and the National Federation of Independent Business in the US Supreme Court, a case described in the New York Times as “a historic test of federal power versus individual liberty”.
The Americans are very keen on their individual liberty, even when that means the freedom to die for lack of access to medical treatment.
As one of the Supreme Court judges who will decide on the constitutionality of mandated health insurance, Justice Antonin Scalia, put it during the hearings: “If the government can do this, what else can it not do?”
The same arguments relied on in the health care case could, he said, be used to “make people buy broccoli”.
Well, maybe they could. But it’s hard to imagine a Congress foolish enough to try.
From this side of the Pacific, the tenor of the debate over the reforms can seem bewildering.
Sure, you can always tussle over the details of a complex package of reform but how, you might wonder, could ensuring all citizens have access to decent health care in itself be a bad thing?
The answer to that can be partially explained by the strange mix of libertarianism and religious faith that is so much a part of American political thought.
An innate suspicion of secular authority — that perhaps goes all the way back to the Pilgrim Fathers — combines in some quarters with a belief that trusting in government is in itself an affront to God.
Never mind the consequences for millions of people facing ill health or worse who cannot afford the care they need.
One of the most moving things I have read recently is an impassioned plea on behalf of the reforms by a woman called Susan Gardner, whose 22-year-old daughter faces an ongoing battle with congenital heart defects.
“It comes down to this”, Gardner writes. “We either let these children die at birth or we as a society agree to spread the cost among all of us. There really is no other way … No one family and no one individual can possibly shoulder the medical cost of ‘miracle’ lives.”
And it’s not just the miracle lives. It’s also the middle-aged clerical worker who loses her job — and therefore her health insurance — just before receiving a cancer diagnosis.
For all the failings of our own health system, I wouldn’t want to exchange places with the Americans. Not even for a whole truckload of broccoli.
Jane McCredie is a Sydney-based science and medicine writer.
Posted 10 April 2012
Sue – There are many different funding models with various proportions coming from specific health related levies and surcharges supplemented with general taxation revenue. However, the point is that it is arguable that the Australian system and the NHS in particular are far from “equitable” systems. Care is NOT universally affordable; if people are not receiving care then it is not affordable. Being patted on the head and put on an interminable waiting list does not represent equitable access. Waiting for 6 months or more to see a pain specialist (hey we get up in arms if terrorists are subjected to pain for a few moments) is not equitable or acceptable. Dying of an MI while waiting for coronary bypass surgery is not representative of universal access to care. Waiting months and months to see a specialist, having a brief appointment (due to the number of people needing to be seen), not understanding what it all meant because you’re in and out so quickly then waiting months again is not acceptable either. The concept that we have a system with “universal” care may comfort our collective conscience. But, especially into the future with an aging population, our system is going to become far from equitable. We need to open up a discussion about different ways of paying for health related care. As doctors with inside knowledge and access to care extended to us as professional courtesy, we’re all right Jack (as the saying goes). We’re not turned away from care when we need it. But that is not the case for many in our community.
Matthias – what you have described as “to have a public health insurance system whereby health insurance contibutions are paid on a percentage of income basis” is exactly what we have with Medicare or NHS. So you are not actually aware of any equitable and universally accessible non-tax=based systems?
Sue — I am sure there are several options to do this, which I have not studied in detail. One option which I am familiar with is to have a public health insurance system whereby health insurance contibutions are paid on a percentage of income basis (e.g. 15%) up to a certain upper limit (people on unemployment benefits have this paid from these benefits). This is called a solidarity principle whereby people with higher income effectively cross-subsidise the health insurance of people with lower income (which is also how it effectively works in a tax-based system). The difference to a tax-based system as in Australia and the UK is that these health insurance contributions are dedicated to health purposes and thereby independent from potential changes in mind of current governments that might decide to dedicate less tax money to health purposes and hospital funding.
Thanks, Matthias. I would be interested to know about those “universal and affordable” insurance-based options. How is it possible to be universally affordable? I have worked in a system (in Canada) that required citizen contributions (rather than tax deductions) into a public system, and that meant that some people where technically “uninsured”. In ED, we provided their care pro bono. How does one ensure that insurance is universally affordable?
Sue — There are also insurance-based options available in some countries, notably in Europe, that universal and affordable. It does not necessarily have to be tax-based like in Australia and the UK. Just another option among the spectrum of how to do things.
I believe it is the entrenched aversion to “big government” that leads US politicians with few options for real reform. The so-called Obamacare package does not offer a basic level of access to all – as do Medicare and the NHS. “Obamacare” is still privately-sold insurance. The difference now is that all insurers are forced to provide a low-cost option. But does that meant that people holding this option have access to the same level of care as all other insured Americans? Of course not. There is no evidence that the US population is ready for government-sponsored, tax-based universal health coverage – the model that works so well in Australia and places like Scandinavia. On the contrary, the legislation that requires every ED to provide care, regardless of insurance status, and without re-imbursement, is just a tax on emergency physicians.
It would be a shame if readers of MJA Insight formed their view of the US Supreme Court challenge to Obamacare from reading Ms McCredie’s opinion piece.
All sides of politics in the US understand the need to reform the healthcare system. How to do it is the question.
The US Supreme Court is hearing a legal challenge about the constitutionality of three components of the Obamacare legislation. The individual mandate to purchase health insurance is the most widely publicized.
Whatever you think about the US healthcare system, the United States has a constitution. The Supreme Court Justices are not there to ponder over the state of healthcare in the US and whether it is fair or not. They are adjudicating on a constitutional challenge to the powers granted to the Federal Government under the Commerce Clause.
As to the legal question, the individual mandate does not appear to meet the necessary conditions to be constitutional, as outlined in the following commentary in the Mayo Clinic Proceedings.
http://www.mayoclinicproceedings.org/article/S0025-6196(12)00198-X/fulltext
Ms McCredie uses sarcasm over a question posed by Justice Scalia about broccoli without any context. This question originated at the District Court level where the legal challenge began. It is fully in line with concepts that have arisen out of previous Commerce Clause jurisprudence over the decades. It relates to defining markets and the tactic of group-and-switch used by the Government’s legal team. Of course it’s got nothing to do with broccoli. Other seemingly irrelevant things such as wheat, marijuana, hotel rental, gun possession and domestic violence form part of the precedent that the court is dealing with in this case.
As to the Patient Protection and Affordable Care Act (aka PPACA or “Obamacare”) it is an atrocious piece of legislation. I am highly skeptical that Ms McCredie has read ANY of it. It is a 974 page bureaucratic monstrosity that would make a health bureaucrat climax with excitement. For every page of legislation there are many fold pages of regulations. It is pure political pandering to the supporters of the Democratic Party. It’s got nothing to do with finding an equitable and fair yet efficient way of providing healthcare. And opposition to it has nothing to do with religious traditions.
The legislation is historically unpopular. Furthermore, previous major reforms impacting on US society have had bipartisan support. An indication of how terrible this legislation is, was the fact that despite having an enormous Democratic majority in the Congress, the legislation passed by only 7 votes. The process also lead to some now legendary promises being made to certain politicians in order to secure their votes.
In summary, if you took the worst of the US health care system and combined it with the worst of the NHS in the UK you would have Obamacare.
There was also a reasonably well written article about this in Annals of Internal Medicine recently by Culter and Gruber: http://www.annals.org/content/early/2012/03/26/0003-4819-156-12-20120619…. One of the puzzling things (for me) is that while there is a debate about whether individuals can be made to buy health insurance, under the current system that is in place, people with urgent health problems and an inability to pay cannot be turned away from emergency departments (which makes sense), and those people with insurance have to pick up the bill by effectively cross-financing this with higher insurance premiums.