Monday, October 16, 2017

Surgeon and health researcher goes home to Appalachia to ask, 'Is health care a right?' and gets differing, evocative answers

Dr. Atul Gawande
"Is health care a right?"

So asks Atul Gawande, a surgeon and public-health researcher, in an article for The New Yorker, after asking it of people in his hometown of Athens, Ohio, in the foothills of Appalachia.

He found that even those who lean toward thinking health care is a right still struggle with the idea of "undeserving" people getting something for free. That means Medicaid, the main instrument of the Patient Protection and Affordable Care Act in Kentucky.

One middle-aged Ohio couple, who had private insurance with a $6,000 deductible and a hefty co-pay and premium, told Gawande that their many health issues had caused them to file for bankruptcy.

And while they both said they leaned conservative, the husband, called Joe, maintained that access to health care is a right, but shouldn't be free. But his wife, called Maria, was conflicted. She said her liberal side believes that "people should be judged by how they treat the least of our society," but her conservative side believes that because "I work really hard, I deserve a little more than the guy who sits around."

Gawande writes that "a right makes no distinction between the deserving and the undeserving," but said this concept "felt perverse" to Maria and Joe.

“I see people on the same road I live on who have never worked a lick in their life,” Joe told Gawande, his voice rising. “They’re living on disability incomes, and they’re healthier than I am.”

Joe stressed that he would be willing to help people who tryto help themselves, but had no desire to help a person who has "spent his whole life a drunk and a wastrel." Gawande writes that "such feelings are widely shared."

But not by everyone. Gawande's friend Tim Williams, a cancer survivor who went three years without a job after chemotherapy and now works as the operator of the town's water-treatment plant, told Gawande that health care is like water: necessary for human existence, and therefore the government has the responsibility to provide it.

Monna French, a 53-year-old librarian at the middle school in Athens, said she had largely taken care of herself and her two children after her divorce, and eventually landed a job at the library that offered health insurance. Calling herself a conservative, she said the idea of health care as a right is just another way to undermine work and responsibility. “If you’re disabled, if you’re mentally ill, fine, I get it,” she told Gawande. “But I know so many folks on Medicaid that just don’t work. They’re lazy.”

But when Gawande asked French and others about Medicare, the program for all people 65 and older, they were all on board -- largely because everyone who works pays into it. Medicaid, funded by federal and state taxes, is open in Kentucky to people with incomes up to 138 percent of the poverty line. At 139 percent, they must rely on private insurance, which they may not find affordable.

French, whose husband is on Medicare, told Gawande, “I believe 100 per cent that Medicare needs to exist the way it does.” Gawande writes, "This was how almost everyone I spoke to saw it. To them, Medicare was less about a universal right than about a universal agreement on how much we give and how much we get."

Gawande says this understanding could be the key to the current political impasse over Obamacare, because a system that gives everyone a different deal is having a "corrosive effect" on America. He drew insight from another childhood friend, artist Arnold Jonas, who pays his bills by working as a mechanic or manual laborer.

Jonas said he doesn't consider health care a right, but does think health policy should be centered around security. For example, he noted that the fire department and police provide security to all of us, and said health care should be the same -- through "collective effort and shared costs." However, he added, "When people get very different deals on these things, the pact breaks down."

Gawande also tells the story of a friend who had been opposed to Obamacare, but after having a heart attack realized the importance of its guarantee that insurance policies cover pre-existing conditions.

Gawande writes in detail about the history of health insurance; he notes the growing "gig economy" that has moved many Americans away from the traditional employer-insurance model; the move away from one of America's fundamental concepts of "shared belonging, mutual loyalty and collective gains;" the high cost of health care, and how that further divides the haves and the have nots; and the divisions that exist around what kind of health care America should have.

"Few want the system we have, but many fear losing what we've got," he writes, adding later, "What we agree on, broadly, is that the rules should apply to everyone."

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