[LST] Atul Gawande: Obamacare and obstructionism.

Atul Gawande: Obamacare and obstructionism.
THE NEW YORKER | SEPTEMBER 29, 2013
http://pulse.me/s/qUr0z

Ours can be an unforgiving country. Paul Sullivan was in his fifties,
college- educated, and ran a successful small business in the Houston
area. He o read more

Ours can be an unforgiving country. Paul Sullivan was in his fifties,
college-educated, and ran a successful small business in the Houston
area. He owned a house and three cars. Then the local economy fell
apart. Business dried up. He had savings, but, like more than a
million people today in Harris County, Texas, he didn't have health
insurance. "I should have known better," he says. When an illness put
him in the hospital and his doctor found a precancerous lesion that
required treatment, the unaffordable medical bills arrived. He had to
sell his cars and, eventually, his house. To his shock, he had to move
into a homeless shelter, carrying his belongings in a suitcase
wherever he went.

This week, the centerpiece of the Affordable Care Act, which provides
health-insurance coverage to millions of people like Sullivan, is
slated to go into effect. Republican leaders have described the event
in apocalyptic terms, as Republican leaders have described proposals
to expand health coverage for three-quarters of a century. In 1946,
Senator Robert Taft denounced President Harry Truman's plan for
national health insurance as "the most socialistic measure this
Congress has ever had before it." Fifteen years later, Ronald Reagan
argued that, if Medicare were to be enacted, "one of these days you
and I are going to spend our sunset years telling our children and our
children's children what it once was like in America when men were
free." And now comes Senate Minority Leader Mitch McConnell describing
the Affordable Care Act as a "monstrosity," "a disaster," and the
"single worst piece of legislation passed in the last fifty years."
Lacking the votes to repeal the law, Republican hard-liners want to
shut down the federal government unless Democrats agree to halt its
implementation.

The law's actual manifestation, however, is rather anodyne: as of
October 1st, healthcare.gov is scheduled to open for business. A Web
site where people who don't have health coverage through an employer
or the government can find a range of health plans available to them,
it resembles nothing more sinister than an eBay for insurance. Because
it's a marketplace, prices keep falling lower than the Congressional
Budget Office predicted, by more than sixteen per cent on average.
Federal subsidies trim costs even further, and more people living near
the poverty level will qualify for free Medicaid coverage.

How this will unfold, though, depends on where you live. Governors and
legislatures in about half the states—from California to New York,
Minnesota to Maryland—are working faithfully to implement the law with
as few glitches as possible. In the other half—Indiana to Texas, Utah
to South Carolina—they are working equally faithfully to obstruct its
implementation. Still fundamentally in dispute is whether we as a
society have a duty to protect people like Paul Sullivan. Not only do
conservatives not think so; they seem to see providing that protection
as a threat to America itself.

Obstructionism has taken three forms. The first is a refusal by some
states to accept federal funds to expand their Medicaid programs.
Under the law, the funds cover a hundred per cent of state costs for
three years and no less than ninety per cent thereafter. Every
calculation shows substantial savings for state budgets and millions
more people covered. Nonetheless, twenty-five states are turning down
the assistance. The second is a refusal to operate a state health
exchange that would provide individuals with insurance options. In
effect, conservatives are choosing to make Washington set up the
insurance market, and then complaining about a government takeover.
The third form of obstructionism is outright sabotage. Conservative
groups are campaigning to persuade young people, in particular, that
going without insurance is "better for you"—advice that no responsible
parent would ever give to a child. Congress has also tied up funding
for the Web site, making delays and snags that much more inevitable.

Some states are going further, passing measures to make it difficult
for people to enroll. The health-care-reform act enables local health
centers and other organizations to provide "navigators" to help those
who have difficulties enrolling, because they are ill, or disabled, or
simply overwhelmed by the choices. Medicare has a virtually identical
program to help senior citizens sort through their coverage options.
No one has had a problem with Medicare navigators. But more than a
dozen states have passed measures subjecting health-exchange
navigators to strict requirements: licensing exams, heavy licensing
fees, insurance bonds. Florida has attempted to ban them from county
health departments, where large numbers of uninsured people go for
care. Tennessee recently adopted an emergency rule declaring that
anyone who could be described as an "enrollment assister" must undergo
a criminal background check, fingerprinting, and twelve hours of
course work. The hurdles would hamper hospital financial counsellors
in the state—and, by some interpretations, ordinary good
Samaritans—from simply helping someone get insurance.

This kind of obstructionism has been seen before. After the Supreme
Court's ruling in Brown v. Board of Education, in 1954, Virginia shut
down schools in Charlottesville, Norfolk, and Warren County rather
than accept black children in white schools. When the courts forced
the schools to open, the governor followed a number of other Southern
states in instituting hurdles such as "pupil placement" reviews,
"freedom of choice" plans that provided nothing of the sort, and
incessant legal delays. While in some states meaningful progress
occurred rapidly, in others it took many years. We face a similar
situation with health-care reform. In some states, Paul Sullivan's
fate will become rare. In others, it will remain a reality for an
unconscionable number of people. Of some three thousand counties in
the nation, a hundred and fourteen account for half of the uninsured.
Sixty-two of those counties are in states that have accepted the key
elements of Obamacare, including funding to expand Medicaid. Fifty-two
are not.

So far, the health-care-reform law has allowed more than three million
people under the age of twenty-six to stay on their parents' insurance
policy. The seventeen million children with preëxisting medical
conditions cannot be excluded from insurance eligibility or forced to
pay inflated rates. And more than twenty million uninsured will gain
protection they didn't have. It won't be the thirty-two million hoped
for, and it's becoming clear that the meaning of the plan's legacy
will be fought over not for a few months but for years. Still, state
by state, a new norm is coming into being: if you're a freelancer, or
between jobs, or want to start your own business but have a family
member with a serious health issue, or if you become injured or ill,
you are entitled to basic protection.

Conservatives keep hoping that they can drive the system to collapse.
That won't happen. Enough people, states, and health-care interests
are committed to making it work, just as the Massachusetts version has
for the past seven years. And people now have a straightforward way to
resist the forces of obstruction: sign up for coverage, if they don't
have it, and help others do so as well. ♦

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Saurav Datta

Twitter: SauravDatta29


"To those who believe in resistance, who live between hope and
impatience and have learned the perils of being unreasonable. To those
who understand enough to be afraid and yet retain their fury."

Sent from my Amazon Kindle Fire

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