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October 4, 2017

Is health care a right? Gawande argues it's time to find common ground

Daily Briefing

Speaking with people from his hometown of Athens, Ohio, Atul Gawande in the New Yorker explores the divisive emotions and politics surrounding the question of whether health care should be a right—and spotlights a possibility for common ground.

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According to Gawande, "The United States remains the only developed country in the world unable to come to agreement" on whether health care should be a right. In Athens, Gawande writes, where the range of health insurance among community members varies widely, that debate is contextualized amid ongoing efforts to repeal and replace the Affordable Care Act.

For instance, one couple in the town, Maria and Joe Dutton, said while people should be able to access health care, they also should be responsible for at least part of the cost. "A right makes no distinction between the deserving and the undeserving, and that felt perverse to Maria and Joe," Gawande writes. "They both told me about people they know who don't work and yet get Medicaid coverage with no premiums, no deductibles, no co-pays, no costs at all—coverage that the Duttons couldn't dream of." On the flipside, however, Gawande spoke with Tim Williams, a childhood friend who viewed health care as one of the "necessit[ies] of human existence," and therefore one of the "essential function[s] of government."

An 'unbridgeable' divide? Maybe not, Gawande writes

The divide between the Duttons' and Williams' perspectives seemed "unbridgeable," Gawande writes, but "the concerns that came with each viewpoint were understandable, and [Gawande] wondered if there were places where those concerns might come together."  

For instance, according to Gawande, nearly everyone with whom he spoke voiced support for Medicare because of its perceived reciprocity. Summarizing the responses he heard, Gawande writes, "From the moment we earn an income, we all contribute to Medicare, and, in return, when we reach sixty-five we can all count on it, regardless of our circumstances. There is genuine reciprocity. You don't know whether you'll need more health care than you pay for or less."

According to Gawande, "Understanding this [perspective] seems key to breaking the current political impasse." He explains, "The deal we each get on health care has a profound impact on our lives—on our savings, on our well-being, on our life expectancy," but "in the American health care system ... different people get astonishingly different deals."

A 'seemingly innocuous decision,' and its unexpected ramifications

Gawande writes that the disparity stems from "a seemingly innocuous decision made during the Second World War," when the Roosevelt administration permitted employers and unions to increase their health insurance benefits—and made those benefits tax exempt—to attract employees. "It didn't seem a big thing," Gawande writes. "But, ever since, we've been trying to figure out how to cover the vast portion of the country that doesn't have employer-provided health insurance: low-wage workers, children, retirees, the unemployed, small-business owners, the self-employed, the disabled. We've had to stitch together different rules and systems for each of these categories, and the result is an unholy, expensive mess that leaves millions unprotected."

Since then, the political debate over health care has seemed to focus less on the underlying system and more on "what the rules should be" for each person's place in the system. But according to Gawande, accepting that system, "and its dismal conception of life as a zero-sum proposition," is a mistake. "It gives up on the more encompassing possibilities of shared belonging, mutual loyalty, and collective gains."

Despite challenges, there's a way forward

According to Gawande, "Few want the [health care] system we have, but many fear losing what we've got." However, while we "disagree profoundly" about what type of health care system to implement, we broadly agree "that the rules should apply to everyone."

Nonetheless, "we've yet to put this moral principle into practice," Gawande writes.

Drawing comparisons with the ACA, Gawande cites the Vaccine Act of 1813, the "country's first health care entitlement for the general population" which eased access to vaccines that might otherwise be out of reach because of cost. However, after an error in the program resulted in a fatal outbreak of smallpox, Congress in 1821 opted to repeal rather than repair the program—and "it was eighty years before Congress again acted to insure safe, effective supplies of smallpox vaccine."

According to Gawande, "The repeal of the Vaccine Act of 1813 represented a basic failure of government to deliver on its duty to protect the life and liberty of all." But Congress' actions later, to reinstate vaccine supplies, perhaps reflects a path forward on the health care debate, Gawande continues. Citing the increase in support for government-backed universal coverage following the ACA's enactment, Gawande concludes, "The fact that public vaccination programs eventually became ubiquitous (even if it took generations) might tell us something about the ultimate direction of our history—the direction in which we are still slowly, fitfully creeping" (Gawande, The New Yorker, 11/2).

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