Like some other progressives, the health care reform fight has left me demoralized, and suffering an acute lack of enthusiasm for cheering for what's left after seeing so much needed and hoped-for change bargained away.
But a lack of enthusiasm doesn't quite compare to a lack of access to health care, experienced by far to those Americans who can't wait for a better bill, as Bill Boyarsky observed among the men and women who rose early (some at 3:00 a.m.) to get a place in line at St. John's Well Child and Family Center in South Los Angeles. They are waiting in line when the center opens at 8:00 a.m., seeking the most basic care.
I walked through St. John's and saw how medical treatment taken for granted by the affluent and insured cannot only save a poor family from disaster but start it on the road upward by providing good health and a better life.
In addition to receiving lifesaving drugs, diabetics are taught the value of diet and exercise. Women who suffer domestic abuse are steered to support groups. Dentists and physicians work on patients and a laboratory backs them up. Mothers and fathers, in parenting sessions, are urged to read to their kids each day. Teams visit homes, looking for lead, rats and cockroaches. "We pull two dozen cockroaches out of kids' ears every week," said Mangia.
Nobody in America should have to live like this, without medical care that other industrial nations take for granted. The health reform bill is a start to ending this evil. Franklin D. Roosevelt, Harry Truman, Bill Clinton — even Richard Nixon — tried to do something about health care and were beaten by the powerful special interests profiting from the present system. The interests, led by the U.S. Chamber of Commerce, the insurance industry and others, are at it again in the final days before the House vote, targeting the members who fear a "yes" vote will cost them their jobs.
I hope they have the guts to resist. "We need courage, that's what we need," President Obama said in Ohio. This bill, as imperfect it is, will begin the process of reforming a health care system that is unfair to the middle class and the poor alike. Health care, as Roosevelt said, is a human right. Passage of the bill would be a great legacy for this Congress.
There are of course, numerous stories and scenes like the one Boyarsky witnessed in Los Angeles. In August, the New York Times covered a similar story of thousands of people with no other access to care lining up to get medical care in the arena of LA's Forum Club.
The Guardian's Ed Pilkington went to Quindaro, Kansas, and at Dr. Sharon Lee's clinic, saw how the poorest in middle America struggle with health care.
Lee has just opened an outpost of her clinic in the outlying neighbourhood of Quindaro, an area of boarded-up houses and deserted factories where work is hard to find and crack plentiful and a per capita income is $11,025. A third of the population is below the federally defined poverty line.
And yet the local health department has decided the only health centre in the area will be closed by the end of this year and moved 30 blocks west to a much more prosperous part of the city where income levels are five times higher. Before long, one of the poorest areas of Kansas — of America — will be left without a single doctor, with only Lee's voluntary services to fall back on.
Even that is academic. Many of the residents of Quindaro were unable to see a doctor in any case — because they were uninsured. In Kansas, anyone who is able-bodied but unemployed is not eligible for government-backed health insurance as is anyone earning more than 39% of federal poverty levels. That leaves a huge army of jobless and low-income working families who are left in limbo. "It's the working poor who are most at disadvantage," Lee says.
As a result, she sees the same pattern repeating itself over and over. People with no insurance avoid seeking medical help for fear of the bills that follow, until it is too late. "When people come in they are already very, very sick. They have avoided seeing the doctor thinking that something may clear up, hoping they may be getting better."
Former health insurance executive Wendell Potter witnessed people in Wise County, Virginia, lining up to receive medical care in livestock stalls.
He flew in corporate jets to industry meetings to plan how to block health reform, he says. He rode in limousines to confabs to concoct messaging to scare the public about reform. But in his heart, he began to have doubts as the business model for insurance evolved in recent years from spreading risk to dumping the risky.
Then in 2007 Mr. Potter attended a premiere of "Sicko," Michael Moore's excoriating film about the American health care system. Mr. Potter was taking notes so that he could prepare a propaganda counterblast — but he found himself agreeing with a great deal of the film.
A month later, Mr. Potter was back home in Tennessee, visiting his parents, and dropped in on a three-day charity program at a county fairgrounds to provide medical care for patients who could not afford doctors. Long lines of people were waiting in the rain, and patients were being examined and treated in public in stalls intended for livestock.
"It was a life-changing event to witness that," he remembered. Increasingly, he found himself despising himself for helping block health reforms. "It sounds hokey, but I would look in the mirror and think, how did I get into this?"
Mr. Potter loved his office, his executive salary, his bonus, his stock options. "How can I walk away from a job that pays me so well?" he wondered. But at the age of 56, he announced his retirement and left Cigna last year.
This year, he went public with his concerns, testifying before a Senate committee investigating the insurance industry.
Potter's testimony lays out what the people waiting outside the Forum in LA fairgrounds in Virginia are up against.
The people waiting outside St. John's, outside the Forum Club, were majority black and Hispanic. The people waiting outside the Virginia fairgrounds were majority white, as are Dr. Lee's patients in Kansas, and as are the majority of the uninsured. They waited at events more than 2,000 miles and two months apart from each other. Yet, as Boyarsky writes, they have much in common when it comes to health care and health care reform.
They are caught between rising unemployment and weak medical systems. But the even the limited health care reform legislation we've got right now will help them where the status quo is currently failing.
The bill would immediately benefit St. John’s Well Child and Family Center and more than 7,500 similar facilities around the country, which provide medical, dental, mental health, parenting instruction and other services to more than 17 million urban and rural poor. The centers are financed by a combination of government and nonprofit foundation funds, plus private donations.
The bill would provide the centers $700 million in the coming year, with annual appropriations eventually increasing to $2.9 billion, according to the National Association of Community Health Centers. The centers would also receive $1.5 billion over five years for construction and renovation.
Jim Mangia told me that the number of clinics around the country would double. St. John’s would get $11 million from the reform bill, permitting more treatment sites and a reduction or an end to lines. “We have to put clinics in the neighborhoods where people live,” Mangia told me. “It’s very difficult to put the kids on a bus and schlep across town.”
The reform bill would also extend Medicaid, the federal-state assistance program. A family of four earning about $30,000 a year would be eligible for Medicaid. This means they could go a doctor near their home, rather than to a distant clinic.
And, no, it's not enough. Not nearly. That's not just a progressive opinion, but a one shared by most Americans, who think the current reform legislation doesn't go far enough.
No pollster, including me, could look at the recent data and responsibly say anything other than that the American public is closely divided when it comes to supporting or opposing various health-care plans. The most recent Washington Post poll (from Feb. 10) shows a narrow gap between support and opposition: 46 percent favor; 49 percent oppose. This data is consistent with eight of the 12 most recent independent public polls reported on Pollster.com.
In light of this data, it is irresponsible, and wrong, for Schoen and Caddell to assert that a "solid majority of Americans oppose" health-care reform.
In fact, two recent polls, including one with the most negative ratings on health care, reveal through follow-up questions that a significant number of people who oppose current plans do so because they don't go far enough rather than because they go too far. Not only is it absurd to suggest that these people would rise up against Democrats for passing the president's plan, it is far more likely that they would join others who support the plan and punish those who tried to block reform or voted against it.
There are a number of political reasons to support health care reform. There's the slim chance that this congress would go back to the drawing board and come up with something better. There's the likelihood that if this congress fails, the next congress may have fewer Democrats, and thus an even slimmer chance of taking up health care reform, and slim to no chance of passing legislation on any other progressive issues. Finally there's the likelihood that if health care reform fails now, it fails for another 20 year.
The people waiting outside of St. John's, outside the Forum, at the fairgrounds in Virginia, or at Dr. Lee's clinic in Kansas don't have another 20 years to wait. They will join the other 45,000 Americans who die annually because they lack health insurance.
What's more, those of us who think we have the luxury of waiting for a better bill, are fooling ourselves. Even in the grips of the current crisis, if we still have jobs and we still have health care, we are easily lulled into buying the illusion of middle class security and independence.
In a consumer culture, where access to credit made it easy to own a house and car, while refinancing a mortgage could meet unexpected expenses, anyone with steady but limited income could join the middle class. The psychology of being in the middle class and the financial reality - or at least the appearance of it - were in tandem, as long as the US economy held up. Then the economy came crashing down. Being middle class is now a mental state only.
Those facing financial ruin can remain in a middle class frame of mind only by holding on to American values of "pulling yourself up by your bootstraps". This means not accepting hand-outs, and it in turn means seeing those that need and accept such help as usurpers. Besides, the moment one accepts help not as a temporary fix but as a permanent institution through government, the illusion of being middle-class collapses. Universal health care, or what remains of it in the public option, is an anathema to those middle class values.
Sure enough, today, less than half of us consider ourselves middle class anymore. That's on illusion shattered. The economic crisis has brought home the economic reality that middle class status has been virtually hollowed out.
The average income for poll respondents who consider themselves middle class is about $55,000 a year. Self-described working class folks earn roughly $35,000, and those who think they're well-off earn $95,000. "But income is far from the sole determinant of self-defined middle class status, likely because family size, expenses, local costs of living and other circumstances also come into it," the poll notes. "Even among people with incomes under $25,000 a year, 41 percent describe themselves as middle class. So do 38 percent of those with household incomes over $100,000."
...The Commerce Department produced a report in January for the Vice President's Middle Class Task Force that objectively measured obstacles to attaining the middle class lifestyle. That report found that it's more difficult to do than it used to be:
"While incomes for married-couple and single-parent families with two children have increased significantly, much of this rise occurred in the 1990s. In part, these increases occurred because parents are working more hours in order to maintain higher income levels," the report said.
"Unfortunately, while incomes have risen, the prices for three large components of middle class expenses have increased faster than income: the cost of college, the cost of health care and the cost of a house. Thus, we conclude that it is harder to attain a middle class lifestyle now than it was in the recent past."
The next illusion to be shattered for those of us who are "comfortably" middle class and employed is that we have health insurance. Really, we don't have health insurance.
If, like most people, your health coverage is through your employer or your spouse’s employer, that is not what you have. At some point in the future, you will get sick and need expensive health care. What are some of the things that could happen between now and then?
- Your company could drop its health plan. According to the U.S. Census Bureau (see Table HIA-1), the percentage of the population covered by employer-based health insurance has fallen every year since 2000, from 64.2% to 59.3%.*
- You could lose your job. I don’t think I need to tell anyone what the unemployment rate is these days.**
- You could voluntarily leave your job, for example because you have to move to take care of an elderly relative.
- You could get divorced from the spouse you depend on for health coverage.
For all of these reasons, you can’t count on your health insurer being there when you need it. That’s not insurance; that’s employer-subsidized health care for the duration of your employment.
Once you lose your employer-based coverage, for whatever reason, you’re in the individual market, where, you may be surprised to find, you have no right to affordable health insurance. An insurer can refuse to insure you or can charge you a premium you can’t afford because of your medical history. That’s the way a free market works: an insurer would be crazy to charge you less than the expected cost of your medical care (unless they can make it up on their healthy customers, which they can’t in the individual market).
Most of us are one layoff away from joining the line at St. John's, the Forum, or the fairgrounds. The reality is that more of us will join the ranks of the underinsured if reform fails. For us, merely maintaining the status quo will mean a huge step backwards.
BUT I HAVE INSURANCE: While most Americans have insurance, many pay exorbitant rates because they have no bargaining power with insurers.
That includes many of the tens of millions who buy their own insurance — the unemployed, the self-employed, and those whose employers do not offer insurance. The recently announced plan by Anthem Blue Cross in California to raise annual premiums by 35 to 39 percent for nearly a quarter of its individual subscribers is a chilling harbinger of what is to come if reform fails.
There are another 48 million people who work in relatively small firms that often cannot get the better rates of large-group coverage. All of these groups should be able to get a better deal if they can buy their insurance through new, competitive exchanges.
If current trends continue, the number of underinsured Americans — those who have coverage too skimpy to pay substantial medical bills or protect them from high out-of-pocket spending — will also rise from an estimated 25 million in 2007 to 35 million in 2011, according to the Commonwealth Fund, a respected research organization.
That will increase the risk that this group will forgo needed care and will expose many more of them to potential bankruptcy if they cannot pay huge medical bills. Some 72 million adults currently have medical debt or problems paying their bills even though most of them have insurance. Reform would help them by setting minimum standards of coverage and providing subsidies to tens of millions of low- and middle-income people to help pay their premiums.
Or we'll join the ranks of the uninsured.
BUT I LIKE MY INSURANCE: Most Americans get their insurance through large companies, with large group bargaining power. While they complain about premiums and paperwork, most seem satisfied with their coverage.
For them the real fear is what happens if they lose their jobs or decide to change jobs. Will they be shut out of coverage because of a pre-existing condition or forced to pay high rates to buy their own insurance?
For this group, the real advantage of reform is security. If they get laid off, decide to be self-employed or switch to a smaller employer that offers no insurance, they will still be guaranteed coverage — even if they are a cancer survivor or have heart trouble or any other pre-existing condition. And they will be able to buy insurance on the exchanges.
That reality is encapsulated by the story of of Dr. Lee's patients, Dr. Joseph Manley. In the span of 11 years, he went from having his own practice, a home in the an affluent Kansas City neighborhood, and a Porsche every year, to an extremely different state, due to health problems that started with involuntary muscle movements and difficulty swallowing. In other words, just because he got sick.
Eventually his lack of motor control interfered with his work to the degree that he was forced to give up his practice. He fell instantly into a catch 22 that he had earlier seen entrap many of his own patients: no work, no health insurance, no treatment.
He remained uninsured and largely untreated for his progressively severe condition for the following 11 years. Blood tests that could have diagnosed him correctly were not done because he couldn't afford the $200. Having lost his practice, he lost his mansion on the hill and now lives in a one-bedroom apartment in the suburbs. His Porsches have made way for bangers. Many times this erstwhile pillar of the medical establishment had to go without food in order to pay for basic medicines. In 2000 Manley finally found the help he needed, at a clinic in Kansas City that acts as a rare safety net for uninsured people. He was swiftly diagnosed with Huntington's disease, a degenerative genetic illness, and now receives regular medical attention through the clinic.
It happened to Dr. Manley just as it has happened and will happen to many more of us who don't have nearly as far to fall. Meanwhile, the safety net is fraying and full of holes. In some places it's just completely gone. It won't mend itself, and insurance companies won't mend it, because they don't profit by doing so.
The choice is simple. The reform legislation we have doesn't far enough, but it's a step in the right direction, as opposed to standing still or moving backwards. But a step in the right direction, however small, builds momentum for the next step forward. By some estimates, progressives made this reform a great deal better than it would have been had we not engaged. When this reform bill is signed into law, progressive should — and I have every reason to believe we will — start the fight to expand it even before the ink dries on President Obama's signature.
We can either take a step in the right direction, or we can take a huge step back. Standing still is not an option.
Neither is waiting. Unless you in good conscience can go down to St. John's or the next Remote Area Medical expedition and tell those people that they and their families are going to have to wait quite a bit longer — and unless you can stand to hear the same thing should you find yourself standing among them — you need to get behind health care reform.
For their sake, and all of ours.
