Rhetoric Meets Reality: Health Care

By Kayla McGrady ’05


Daniel Groll, associate professor of philosophy, teaches medical ethics
Natalee Johnson, advanced practice nurse, coordinates medical services at Student Health and Counseling
Iveta Jusova, professor of women’s and gender studies, leads an off-campus program in Europe on women’s issues, including health care policy
Richard Keiser, professor of political science, teaches about the politics of the American medical system
Marit Lysne, director of Student Health and Counseling, oversees Carleton’s efforts to ensure that all students have access to medical care and counseling services
Alfred Montero, Frank B. Kellogg Professor of Political Science, teaches about comparative international health care systems
Austin Robinson-Coolidge, director of technology support, helps negotiate Carleton employees’ health coverage as chair of the benefits committee

How can other countries’ health care systems help us analyze America’s?

Montero: Among the advanced capitalist countries, we have the highest infant mortality rate and some of the worst numbers for childhood mortality and life expectancy. Most of the national health care systems that are outperforming us are heavily public. They guarantee universal access and provide a strong cushion based on taxpayer resources. But despite our worse outcomes, our costs are almost double what the French pay and triple what the Germans and Scandinavians pay.

Robinson-Coolidge: [Based on my insurance research on behalf of Carleton’s benefits committee] I believe that systems like the Scandinavians’ work [economically] because doctors are paid a salary instead of by procedure. Americans haven’t been willing to take that step because there’s a strong—current and historical—national sentiment that medical providers should be allowed to charge what the market will bear. But it’s difficult to reconcile that principle with a goal of equitable health care for everyone when there’s economic disparity in the populace.

Keiser: You’re pointing to interest-group democracy. Pharmaceutical companies, insurance companies, the American Medical Association, and various other organizations are powerful actors in the American political system. Many of Europe’s universal health care systems were created in the midst of postwar crises, when the adherence to norms of democracy, like interest groups having representation and power, were set aside for “the public good.” People make concessions during crises that they’d otherwise be unlikely to make.

Groll: Many Americans are scared by the rhetoric used to describe universal care, especially when it’s described as “socialized medicine”. For example, people don’t want rationing. They assume we don’t have rationing in the United States while places like Canada do, as though there isn’t de facto rationing in a system where it’s difficult to access anything but emergency care if you don’t have money. It’s true that the government gets to decide what’s covered in Canada, but it’s false to think that you, the consumer, get to decide in a private system like ours.

Jusova: The socialized health care systems in Europe were born in societies where everyone already used “welfare” at some point in their lives. That’s because Eastern Europe has a history of socialism and Western Europe’s pervasive liberalism comes from a different school of economics than the Chicago school that heavily influenced U.S. liberalism. While American neoliberalism is all about individuals being responsible for themselves, Western European liberalism puts more emphasis on social welfare for everybody, so “welfare” doesn’t have the same negative connotations in Europe that it has here.

Can you put recent debates on women’s reproductive health into context?

Jusova: Controversy over reproductive rights isn’t just an American issue. There are also strenuous debates in Europe right now. For example, because Poland used to be part of the Soviet bloc and Marxist ideology focuses on equality between the sexes, abortion was quite accessible there decades before it was available in the United States or Western Europe. But Poland had close ties to Pope John Paul II so, basically as a gift to him, the new leaders enacted strict abortion laws in 1993 shortly after the fall of the communist regimes in 1989. Now, under Catholic influence, they’re discussing whether to eliminate the three remaining provisions for abortion: rape, incest, or the health of the mother. The push against women’s reproductive rights got particularly strong after the Church’s pedophilia scandal, when it was losing ground in Poland. It needed to refocus the public’s attention.

But it’s important to remember that when we talk about reproductive rights, abortion is just one of the issues. The Affordable Care Act (ACA) is also intended to improve infant mortality rates, pre- and postnatal care, and access to and affordability of contraceptives.

Johnson: The effects of the ACA’s increased access to birth control have been statistically significant. We’re seeing a reduction in abortions because of a reduction in unintended pregnancies. And access to long-acting, reversible contraception like IUDs makes a big difference in younger populations like ours at Carleton.

Robinson-Coolidge: Contraceptive coverage has a relatively low impact on the overall cost of insurance. But it has a huge effect on the quality of people’s lives.

Lysne: Beyond access, Americans also need more education about reproductive health.

Johnson: Many students come to Carleton’s Student Health and Counseling office as a follow-up to visits with their regular providers because they don’t understand the test or birth control they were given. With the production model in insurance-based clinics, practitioners don’t have much time to answer questions, and students might see someone different each visit, which makes them feel less comfortable talking with their provider.

Lysne: We need to do a better job of teaching young people that it’s okay to talk about sex. I respect that there are differences of opinion on sex education, but the stigma affects health care, and a lot of other areas as well.

Jusova: Part of the reproductive health debate worldwide is a push back against third-wave feminism and its deconstruction of masculinity. This periodic backlash is common in civil rights issues—like Jim Crow laws after the abolition of slavery. So, for example, you’ll see a different sort of hegemonic, alpha male in Donald Trump’s governing style than you saw in Obama’s. And that’s a trend in politicians coming into power elsewhere, too—Geert Wilders in the Netherlands, for example. Because the United States is a superpower, people around the world watch what happens here. The ultraradical forces are emboldened by what they see here.

The American religious right is attempting to consolidate evaporating power, but the influence of nonreligious people is increasing [and the number of them, according to Pew Research Center]. The question is by how much and for how long, and that’s difficult to predict.

Should we repeal, replace, or reform the Affordable Care Act?

Montero: As we think about how to deal with rising premiums, we must remember there are laws of health care economics that we can’t ignore any more than we can suspend gravity. In a private system, there must be systems of subsidies to deal with adverse selection [those most likely to need insurance payouts are also the most likely to choose to purchase insurance]. To those who say the notion of paying in for other people’s health care is un-American, I say, “You do not understand how insurance works.”

Keiser: Insurance works by bringing young, healthy people into the system to offset the costs of people using more care. So younger people who don’t have a preexisting condition are primed to complain about paying too much, but if they drop out, the price goes up for everyone—as long as we continue to cover people with preexisting conditions.

Robinson-Coolidge: So the payoff for many people won’t come [unless] they become sick or something catastrophic happens. People aren’t wired to act against their short-term interests.

Keiser: It’s redistributive, too, which irks people who are privileged because of their jobs and therefore believe they don’t need the Affordable Care Act and yet are being taxed for it. Plus, the ACA is expensive, so people want a better solution. But it’s important to note that in recent years Congress only allotted about 20 percent of the total allowances they’d promised for the ACA. Because insurance companies came up short in the subsidies they expected to receive, they raised premiums and many bailed on the exchange system. They would arguably get back in if there were some guarantee that promised money would be paid in the future. Perhaps that’s more likely to happen with a president and Congress from the same party.

Robinson-Coolidge: Somebody convinced the insurance companies to play a very long game. ACA was designed to produce profits for insurance after a number of years, when pools of money from newly insured healthy people surpassed the initial losses from getting care (all at once) to newly insured people with preexisting conditions. Insurance companies won’t have a chance to get those projected returns if ACA is dismantled before the numbers have time to balance out.

Keiser: One of President Trump’s ideas is to lower prices by creating competition across states, which is already happening in the most populous counties where multiple health plans are competing. That’s a great idea on paper, but there are huge barriers because of states’ different insurance regulations.

Robinson-Coolidge: That’s why plans aren’t currently done that way. So you come back to federal rights versus states’ rights. If regulations were set on a federal level, interstate competition would be much easier, but as long as states are allowed to continue setting their own regulations, it will remain very difficult for plans to compete across state lines.

Keiser: That’s where the public option comes in. When the government enters the market, it can absorb losses and fill the gaps for places where the market itself isn’t doing the job. The government is such a large actor that it drives the price down, as we’ve seen in some cases with pharmaceutical companies. It’s important to note that those drug plans were instituted by a Republican president: George W. Bush. So that could theoretically be an option for places where there isn’t currently competition.

Montero: Congress could try to shield people from rising premiums by creating high-risk pools, made up of the 10 percent of potential insurance clients who account for two-thirds of our medical spending on people under age 65. Before ACA, there were high-risk pools, but they were mostly terminal cases. If you take away lifetime limits for high-risk pools and the limits on discriminating against people with preexisting conditions, there will be a lot more people who stay in those pools much longer. Who’s going to cover that increased risk, if not other policyholders [as is happening now]? Insurance companies? Their stockholders would dump them and the system would crash. Uncle Sam? That’s a huge tax liability.

Keiser: Now that Republicans have gotten their mileage out of opposing ACA, maybe they’ll end up making a few minor changes, replacing the individual mandate with Trump’s health care savings account subsidy idea—which similarly motivates healthy people to participate by giving them money they can only take if they contribute their share—and give it a major rechristening with a lot of political theater. People would make a show of burning Obamacare, but the new law wouldn’t be all that different.

Montero: They might try to use elements of Representative [now U.S. Secretary of Health and Human Services] Tom Price’s plan, which would pass the costs on to the states. [Elements of Price's plan are present in Speaker Paul Ryan's "A Better Way" plan.] The federal government would distribute tax rebates and incentives for the states to individually reform their health care systems. What would that mean in a state like Minnesota where Republicans have a one-seat majority in the Senate and Democrats have the governorship? Chaos. It’s like watching a slow-motion train wreck. We’d have to bail out the insurance companies and the hospitals, all of us would end up paying a lot more for health care, and millions of people would be priced out of coverage.

And it’s only going to get worse, because we live in a country where more than 70 percent of our GDP is in services. We’re losing 175,000 manufacturing jobs a month, service sector jobs are churning, and those jobs are being replaced (if at all) with jobs that don’t have benefits. So a lot of middle-aged people are going from jobs with benefits to jobs without benefits and a reduced wage, and then shopping for health care on the private market where expenses are soaring. How many more jobs will be lost in the next two to three years while the government is fumbling around trying to find an alternative—especially if the individual states have to do it? Many more than the initially projected 30 million people will lose coverage.

One of the unintended consequences of proposed Republican plans is that we could end up with national health care in four years because the government will have to nationalize hospitals and insurance companies to bail them out.

Lysne: The ACA isn’t a perfect system, but there are some good parts to it I hope can stay. For our community, having students be able to stay on their parents’ insurance until they’re 26 was huge. Starting out, they’re more likely to go into jobs that don’t have benefits, and without the individual mandate they might not choose to invest in health care because they’re young and generally healthy, so they feel invincible.

Johnson: Somehow there’s a myth that the old way was good and we can go back to that. Replace or improve is better than repeal. I think we can agree there’s a lot that needs to be improved under the ACA.

Lysne: We haven’t addressed our mental health crisis. Most communities don’t have enough mental health care to support themselves. There’s always a wait list. I’d like to see a system that actually values mental health—not waiting to offer help until people are in crisis.

I’d like to see the same proactive approach you see in our niche of college health care adopted in the wider system. We’re fortunate to be able to work outside the insurance system, so we can provide mental health services beyond what’s deemed “medically necessary.” Early intervention in mental health issues is linked to much higher recovery rates.

Where can we learn more?

Montero: In a country of 300 million people, the circulation of the five most-important national daily newspapers doesn’t crack 10 million. Most voters are low-information voters—educated but uninformed. They’re just busy with life’s chores, and we can all sympathize. So read the news. Get informed. To understand the historical struggle over health insurance in the United States, read Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform, a tour de force by policy expert Paul Starr.

Keiser: If you’re looking for a reliable source for health care data and information, the Kaiser Family Foundation website is the best source.

Groll: To learn more about how our health care system compares to other countries’, read The Healing of America by T. R. Reid. It’s about how the same injury would be treated in different places, and it’s an excellent primer on how different health care systems work. It was written in 2010, but the updated version has an appendix that factors in the ACA.

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