Atul Gawande is a medical physician in Massachusetts whose work on implementing checklists before surgery has saved countless lives worldwide and will save countless more. He is among the most perceptive writers on the American healthcare system.
This is the best short summary I’ve seen of what to expect in the next several months in the politics of health reform.
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.