From IWU Magazine, Winter 2009-10

A Picture of Health

Political scientist Greg Shaw unravels the complex history
behind America’s ongoing healthcare debate.

For more than a century, the role government should play in providing health care has been hotly debated. While Americans have long availed themselves of government-sponsored healthcare programs such as Medicare, they continue to resist pushes toward a national health insurance program. As a result, the United States continues to be the only industrialized democracy without a national healthcare plan.

Associate Professor of Political Science Greg Shaw discusses public policy insights in his new book titled The Healthcare Debate, which pools a variety of political and medical points of view.

Associate Professor of Political Science Greg Shaw looks at this and other issues in his new book, The Healthcare Debate, a volume in Greenwood Press/ABC-CLIO’s Historical Guides to Controversial Issues in America series. In his book, set to print this March, Shaw incorporates the insights of specialists, policymakers and political scientists to view the scope of the healthcare debate throughout U.S. history.

“Health care is likely to remain a dominant issue for the current generation and well into the foreseeable future,” says Shaw.

On Nov. 7, the U.S. House of Representatives passed H.R. 3962, the Affordable Health Care for America Act, which would be the most significant expansion of health care since Congress launched Medicare in 1965. At our press time, it appeared likely the Senate would not vote on its version of the bill until after the new year, “injecting election-year politics more deeply into the debate,” according to the congressional newspaper The Hill.

In early November, just days before the historic House vote, Shaw sat down with University Communications writer Rachel Hatch to help provide a context for the ongoing healthcare debate in America. Their conversation follows:

Why did you decide to tackle the topic of health care at this time?

As a political scientist, my main interest in social policy is welfare and health care. So I think and teach and write a lot about those topics. I’d already written a book on welfare policy in America and this seemed like a good time to address the healthcare side, especially with the ongoing debate surrounding healthcare legislation.

I also wanted to write a book that would bring together a lot of diverse insights and arguments about the role of government in health care. Much of the literature on the subject tends to be very polemic. You know, “It’s all the fault of those hard-hearted conservatives that we don’t have reform” versus “What’s wrong with those soft-headed liberals trying to ruin our health care with government interference?”

And then there is very specialized literature, which bores down deeply into issues that get to be quite esoteric, even for specialists. I thought, “Wouldn’t it be helpful to bring together these different lines of discussion — and also the perspective of a political scientist — into one book?”

The public discourse on the proper role of government in health care has stirred strong emotions. Does it surprise you that people feel so strongly about it?

Well, this is not like tweaking how we do foreign aid, which is one half of one percent of our spending. Health care represents a sixth of the nation’s economy, so it’s a big deal. A lot of people are affected, directly and indirectly, by this.

Secondly, it’s intimate for people. As opposed to how we build interstate highways or national parks, how people get their heath care is something they care really passionately about. And because most folks don’t know very much about the ins and outs of financing and delivery and government involvement, they’re wide open to scare tactics and hyperbole and willful misinformation about things like “death panels.” These kinds of falsehoods play on people’s fears about these very personal, life-and-death issues and also appeal to the general distrust of government that most Americans feel to some extent.

At this point, people seem to be most concerned about the government interfering in their relationships with their doctors.

That’s very true. What’s interesting to note is that HMOs have already interfered with the doctor–patient relationship quite a bit, by limiting who you can go see and the services they might be encouraged to provide and so forth. But Americans really cherish this notion of the doctor–patient relationship and many of them are afraid that further government involvement is going the way of coordinating healthcare provision.

You mentioned liberal and conservative points of view on health care. How have those perspectives shaped the ongoing debate?

Any discussion of the government’s role in providing health coverage quickly runs into a deep divide between conservatives’ market sensibilities and liberals’ eagerness to see government as a workable solution. One of the most interesting aspects of this debate is how much the American people really embrace both these perspectives in different ways. As has been noted by others, Americans tend to be ideologically conservative but programmatically liberal. In other words, they don’t like proposed big-government fixes in the abstract, but they defend particular programs, such as Medicare, which benefit them personally.

There’s an example of this in my book, taken from a town hall meeting in the 1990s where President Clinton’s heath plan was being discussed. A woman there was getting fed up with all this talk of the government meddling in medicine. So she stood up and yelled, “Next thing you know, the government will want to take over Medicare!” I heard that same thing said at a town hall meeting this past summer.

In your book, you propose that a lot of the debate surrounding health care is not really about health care. What is it about, then?

It’s about money, professional autonomy and money, in that order [laughs]. I looked closely in this book at the role of the AMA [American Medical Association]. Its influence on this whole debate has been enormous.

For much of its existence, the AMA has spent a lot of its energy trying to prop up, bolster and reinforce the economic position of its own practitioners. And, in doing so, it’s also been the main obstacle to government involvement in healthcare financing. For example, it fought tooth and nail against Medicare all the way through, and even threatened to boycott it after it had been signed into law.

But there’s been a very interesting development in just the past six months, coming after the Obama administration signaled its willingness to maintain a certain level of reimbursement under Medicare — which accounts for one-fifth of the country’s healthcare spending. In exchange for that, the AMA stood down as an active opponent of reform.

Now it’s the insurance industry that’s become the biggest player against proposed healthcare legislation and is spending millions of advertising and lobbying dollars to try to kill it.

You mentioned earlier the debate over whether or not health care is best managed through a free-market system. How does that position hold up in your analysis?

That’s an aspect of this debate that really fascinates me — the extent to which healthcare purchases are like other market purchases. So, do you buy medical goods and services in the same way you buy a car or a house or macaroni and cheese? If the answer is yes, then market-based solutions make all the sense in the world. But if the answer is no, then you’re barking up the wrong tree.

I simply don’t see health care working like other efficient economic markets. Wealthy people don’t ask for major surgical procedures, for example, simply because they can afford them. And poor people don’t avoid going to an emergency room when they are critically ill or injured. Beyond that, the healthcare system we have now is not especially market-based, since the relationship between what one pays for private insurance and what one gets in return is only very loosely related. And I just don’t see America moving to a purely out-of-pocket payment system at this point. So, I’m skeptical that free-market theories have much practical application in solving problems we’re facing in modern healthcare delivery.

On the other side are progressives who support the idea that health care should be considered more of a right than a privilege. Do you think that has been an effective argument in shaping public opinion?

At a joint session of Congress, President Obama outlined healthcare reform plans. Public reaction has been mixed. Shaw observes that most Americans are wary of "big-government fixes," while at the same time defending specific programs such as Medicare.

The idea that health care should be a right of citizenship, akin to K-12 public education, has been around for some time. But while many Americans believe in universal access to basic medical services as a right, a more expansive understanding of a right to health care hasn’t gained much traction beyond the liberal base.

There may be something to be learned from the argument made for workers’ compensation back in the 1930s.  It wasn’t an idealized argument about social citizenship — it was: the faster you can get these guys healed up and back on the job, the faster they can be productive on the assembly line or whatever they were doing.

Because it was a very practical argument, it carried the day, and workers’ compensation programs spread across the states very rapidly in the 1930s. But instead of going that route, many health-reform advocates have held fast to the idea of it being a basic right of citizenship, as opposed to arguing, “Let’s get people productive and back into the labor force.” It seems to me that if you were to focus more on that kind of practical argument, you might move some moderates in this debate.

What lessons do you feel we have learned as a country since the creation of Medicare in the ’60s?

One insight is that the more we do the more we can do. So, we created Medicare and Medicaid in 1965 and we did not slide into socialized medicine automatically as a result of that, as many conservatives had warned. The economy didn’t crash and burn.

And so, as a nation, we gradually build on prior experiences and we come to have less fear, in this case, of government involvement in financing health. We’ve arrived at a point of general acceptance of the concept of socialized financing of a lot of health care — but not the socialized provision of it. So, doctors don’t all work for the government, but they get paid through a lot of government programs. Unfortunately, in the current public debate, that distinction is often lost. People think we’re talking about socialized medicine, but that’s not what’s on the table in current healthcare legislation.

Polls show that Americans want affordable health care but also want the best health care that’s out there. Is it possible to have both those things?

I think the tension between those two desires is growing, in part because of our advancing medical technologies. Those technologies enable us to do so much more to heal and to cure — but they can cost a lot of money and have also raised people’s expectations as never before. People automatically think, for every problem large or small, “I want the best, the fastest treatment available.” And they turn on the TV and see ads that are essentially telling them, “Go out and twist your physician’s arm to prescribe you this drug.” So, we’re pushed by technology and by marketing to keep demanding more of our health care, and it keeps getting to be a bigger and bigger part of our economy.

Isn’t health care also taking larger and larger chunks of people’s personal incomes?

If you look at the costs, the average American will spend about $7,500 this year on health care. For the average family, healthcare premiums have jumped more than 25 percent in the past five years — from around $10,000 in 2004 to $12,680 in 2008. At that rate of inflation, the average premium is going to be about $30,000 within a decade.

I don’t know about you, but I can’t afford that. I don’t think most of us can. So if we’re going to be honest with ourselves, we can’t keep going down this road.

If there’s a glimmer of hope in this whole conversation it’s that, for a long time, the status quo of doing nothing has been everyone’s second favorite option. But I believe that’s changing.

I was on a panel discussion the other day with the CEO of BroMenn Healthcare System. And he opened his comments by saying, “My greatest fear is that we will do nothing.” Now, he’s no ideologue — he’s a practical guy who has a hospital to run.

I think that’s a conclusion virtually everyone can agree on: that doing nothing is no longer an option. Now that doesn’t mean that compromise or resolution on these very complex issues will, all of a sudden, be a snap. But I think we’ve turned the corner in the last decade in realizing that the status quo is no longer tenable. I think that’s why the current healthcare legislation being proposed by the Democrats has gotten as far as it has — though of course it remains to be seen how many of those reforms will actually become law.

How hard is it to write a history of the heathcare debate when much of that history is just now taking place?

You struggle a lot with verb tense [laughs]. Is this an “is” or a “was”? I actually struck a bargain with my editor. I would send her the last chapter, with the caveat that in the copyediting stage I get to go back and rewrite it, because I’m having to leave this very much in the air about what these bills in Congress are doing. But in terms of how we got here in the first place, I think the book will continue to hold value in answering that basic question, no matter what the outcome.

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