The ideological ambiguity of health care reform during Obama’s first term concedes few absolute truths. The enterprise of reforming health care by way of corporate regulation ignites debate across the left spectrum about the Affordable Care Act’s place in the 2012 election and beyond. Like it or not, the rules of the ACA are now the chessboard for health activism today. Meanwhile austerity-minded state governments provide an ominous backdrop for the ACA.
The ACA’s complex provisions are a way to reconcile the paradoxical goals of maintaining a costly profit-driven system of health financing while expanding access to the poor, the sick, the jobless, the young, the middle class. Rather than ending private, for-profit health financing, the ACA preserves it, including many of its faults. Among these, the ACA still does not achieve universal care, and the recent Supreme Court ruling may set this back further.
This is what health care reform looks like in an era of corporate ascendency.
Consistent with the regressive social values of our time, the ACA is not predicated on the longstanding notion that preventive health care is a fundamental human right. It does, however, make tentative but potentially significant shifts toward preventive medicine. Realizing this potential will take political support inside the halls of power, activism outside them, and an abundance of state-level innovation.
One misconception about the ACA can undermine its potential for progressive change moving forward: its supposed unpopularity. True, overall support for the ACA hovers below 50 percent, but polls have also shown that antipathy toward that law was driven more by the process of lawmaking than by the substance of the law. Moreover, keep in mind that many critics of the ACA would rather expand than repeal many of its provisions.
The provision barring discrimination for pre-existing conditions had 67 percent public support, according to the Henry J. Kaiser Family Foundation. Expanding prescription drug coverage for seniors drew 74 percent support. Subsidies for individuals purchasing health insurance drew 75 percent support. Expanding Medicaid — a provision many states may reject — had 69 percent popular support. Even a redistributive measure, a modest increase in the payroll tax for wealthier Americans, was supported by 59 percent of the public.
What “consumer” of private health care would not want the simplified health plan summaries that are part of the forthcoming state healthcare exchanges? It turns out, very, very few. That provision had 84 percent support in Kaiser Foundation sampling. Of the major provisions, only the individual insurance mandate is unpopular. Regardless of the makeup of power in future terms, it will be difficult to tell the voting public that its repeal would throw out a number of popular babies with the unpopular bathwater.
So what is at stake?
The biggest question is not whether the ACA will be repealed, but how badly needed new funding for public health will be implemented. Perhaps the most overlooked bright spot in the ACA is its emphasis on preventive medicine. The American Public Health Association argues that the ACA, if properly implemented, could “transform our health system from one that treats sickness to one that promotes health and wellness.”
Appalling bellwethers illustrate the need. The infant mortality rate in the US is three times that of Sweden thanks to inadequate pre- and post-natal care. Our low life expectancy — a full five years below that of Japan — shows an inhumane lack of attention toward preventing chronic diseases, particularly among the poor. The APHA notes that sixty percent of deaths in the US are attributed to largely preventable diseases. Incredibly, recent evidence suggests that vulnerable cross sections of US population may be living shorter, less healthy lives than did previous generations.
Innovations in modern medicine may be proceeding apace, but an unfair system of health financing combined with inadequate public health infrastructure is leaving people behind. The harsh truth is that expensive treatments without preventive public health measures only make inequality worse.
The ACA has the potential to breathe new life into preventive care, long a low priority. Health insurance by its nature is modeled to address costly, catastrophic health problems on the back end, rather than preventive measures up front. This could well change under the ACA, which requires that insurers, including Medicare, provide preventive health services without co-pay (though provocatively it does not fully require this of Medicaid, whose impoverished clientele apparently remain a lesser priority).
The ACA creates a new body within the Department of Health and Human Services to coordinate public health at the federal level. This promises more effective allocations of new resources, but questions remain over how much new funding will be there at all in the coming years. The ACA promises $15 billion in new funding for public health, including community prevention initiatives, disease surveillance, research, and accessible community clinics. These funds could be misused or diverted in the best of times, let alone under leaders who are hostile to the enterprise.
With new funding at stake, the time-honored question of “who gets what” will only intensify. Public health activism at the grassroots level will be essential. Preventive care must be politicized, thus subject to democratic scrutiny. The movement for universal “primary care” by village activists and health workers in developing countries spearheaded one of the most concerted efforts to realize health equality. By doing so this movement raised awareness about the political, social, and economic determinants of health. The primary care movement’s culminating document, the World Health Assembly’s 1978 Alma Ata declaration, in effect served an indictment to extreme laissez faire capitalism. Grassroots care coincided with grassroots activism.
Will the ACA help or hinder a similar movement domestically? Time will tell, but what is clear is that the ACA increases the number of stakeholders in our public health system. It grants access to the poor, the sick, the young, the unemployed, and relies on emerging classes of health professionals who promise to play expanded roles in underserved communities. Better education, monitoring, and surveillance embedded in the ACA may well make evidence-based public health activism more effective, as well as more likely.
Finally it is worth remembering that, far from being top-down, much about the ACA’s implementation is left to states. This is frustrating because many states will defy principles of health equality in the coming years. More funding for preventive care may merely replace funds cut by cash-strapped states. Promising new funds for Medicaid, a system the ACA relies on to expand coverage, will meet state health systems that have undergone devastating divestitures.
This is what health care reform looks like in the age of austerity.
Lingering state budget crises remain an existential threat to expanding access. Nevertheless, state innovation will be essential. Recall that Massachusetts served as the model for health care reform in 2010. Long before that limited measure, Saskatchewan served as the model for Canadian Medicare, Canada’s universal health care system. That was not a gift granted by benevolent governments. It was an incremental change brought about by hard-fought political battles.
Vermont’s “Green Mountain Care” promises to be the first truly universal health care system in the US. In this case, the results are mixed. The ACA proved flexible enough to allow the system to proceed, but compliance with ACA rules will delay it. On the other hand, the ACA means that valuable new federal funds will be available for Vermont and other states seeking to follow its example. Such are the vicissitudes of pursuing universal inclusion under a set of rules that will not be reversed, but are not final.
Joshua K. Leon is an assistant professor of Political Science and International Studies at Iona College and is working on a book called The Rise of Global Health. This article is adapted from a speech given as part of Iona College’s Faithful Citizenship series.