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
“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
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
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
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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