Yearning for Universal Coverage Is Not Universal

Posted on | June 16, 2008 | Comments Off on Yearning for Universal Coverage Is Not Universal

Many still view universal coverage with apprehension, not anticipationEveryone wants universal health coverage, right? Not quite. As I pointed out in a recent opinion piece for the Washington Post, the yearning for universal health care is far from universal. The reaction to that article – about 160 posted comments or direct emails to me – confirmed that assessment. So did the lack of reaction from certain quarters (more on that below).

In the article, I wrote:

Here’s a cold truth: Despite much media hand-wringing on the subject, most of us give about as much thought to those who lack health coverage as we do to soybean subsidies. The major obstacle to change? Those of us with insurance simply don’t care very much about those without it. It’s only when health care costs spike sharply, the economy totters or private employers begin to cut back on benefits that the lack of universal health care comes into focus. Noticing the steadily growing ranks of the uninsured, the broad American public – "us" – begins to worry that we’ll soon be joining the ranks of "them."

News media and interest group profiles of uninsured individuals focus disproportionately on middle-class whites, I charged. The reality, however, is this:

Two-thirds of those without health insurance are poor or near poor, according to the Kaiser Family Foundation. And there are clear disparities in how different racial and ethnic groups are affected. Only 13 percent of non-Hispanic white Americans are uninsured, compared with 36 percent of Hispanics, 33 percent of Native Americans, 22 percent of blacks and 17 percent of Asians/Pacific Islanders….

If a lack of health insurance were truly a white middle-class crisis, then conservatives and liberals would long ago have joined together, carved out a compromise and done something.

After criticizing Republicans and Democrats, minority group political leaders and prominent health care foundations, I concluded, in part:

Over the years, our society has gradually provided a medical safety net for the elderly and disabled (Medicare), the poor (Medicaid) and veterans. At one time, these commitments were controversial, and there’s no doubt that they’re expensive. Yet…[i]t’s our willingness to be our brothers’ keepers that in part defines who we are as Americans.

OK, I admit it: the truth is more nuanced. Compassion is just one of our traits. The theme of rugged individualism and self-reliance, for example, plays a large role in our national myth. Back in 1949, the New York State Journal of Medicine bemoaned the way advocates of health insurance (versus 100 percent self-pay) ignored the lessons of Darwin:

Any experienced general practitioner will agree that what keeps the great majority of people well is the fact that they can’t afford to be ill. This is a harsh, stern dictum, and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor?

None of the comments on my article went quite that far, but the gist of many was similar: the uninsured either wouldn’t need insurance if they better managed their own health or would be able to afford it if they better managed their money. So why should I help bail them out?

Others simply invoked the dreaded specter of “socialism.” The canard that universal coverage equates to “socialism” was reportedly instituted by an American Medical Association PR consultant during the Truman administration, but it continues to be wielded cynically today. Pointing out that every other nation in the industrialized world has some form of universal coverage has little impact on an electorate socialized, as it were, to ignore the examples of Germany, Switzerland and a host of other nations.

Of course, there were respondents who called for a Canadian-style system, blamed all evils on insurance company greed or said we needed first to solve the problem of soaring costs. Others were simply grateful that the problem of the uninsured had been highlighted.

But here’s what nobody said: No one addressed the issues of race, class and political and economic self-interest that were at the heart of the article. Indeed, I saw no comments or emails from anyone identifying themselves as black or Hispanic.

Physicians, meanwhile, continue to almost as fragmented as the general public. While a recent survey in the Annals of Internal Medicine found that 59 percent said they support legislation to establish a national health insurance program, while 32 percent opposed it, there were glaring gaps among specialties. For example, psychiatrists were overwhelmingly in favor, while general surgeons were barely so.

Meanwhile, in a less-publicized study by the firm LocumTenens, 63 percent of respondents said they would “continue practicing like they do today,” if universal health care were implemented, 11 percent would change occupations and nine percent said they would retire.

Even if the answers are skewed towards self-selected respondents, a distressing number of physicians continue to react to universal care less like, “I am my brother’s keeper” and more like, “Don’t tread on me.” So do their patients.