Early in the morning, half awake, I heard my husband let out a whooping cheer from somewhere in the house. “I can’t believe it,” he kept saying. Like most of my friends, he--a Director of Public Health--- was sure the Supreme Court would never uphold the patient Affordable Care Act (ACA), President’s Barack Obama’s signature effort of his years in office.
Designed to increase the number of people covered by health insurance, by restructuring the fragmented, expensive and ineffective American health care system, Congress passed this historic—though very imperfect---bill in 2010. Republicans, nearly apoplectic, argued that the ACA violated the Constitution because it required each individual to buy medical insurance. (If they couldn’t afford it, the government would subsidize the poor). Most legal scholars viewed it as an easy victory for Obama. But clouds began to gather as the Court sounded increasingly skeptical as the case was argued before them. Then, on June 28, 2012, much to the shock of many liberals, the conservative United States Supreme Court ruled that most provisions of the ACA are constitutional.
Nail-biting days had finally ended. To our astonishment, Chief Justice John Roberts Jr. sided with the four liberals on the court, three of whom are women. Finally, after decades in which three other presidents had failed to provide health care for Americans, President Obama had succeeded.
No, it’s not what I wanted. I wanted Obama’s original “public option” that would have competed with and therefore reduced the power of private insurance companies. For that, however, he could not get legislative support. Many of us wanted to expand Medicare (for those over 65 years of age), or some other kind of single payer system. Best of all, many of us had dreamed of some integrated system that would cover all Americans and reduce our astronomical health costs caused by a private, fragmented, failing health system.
But the obstacles had been formidable. Senate Republicans spoke ominously of “death panels” and cleverly changed the terms of debate, warning that health care (for the poor and middle class) would cause the “debt” to skyrocket and destroy the American economy. As New York Times columnist Paul Krugman wrote, “what was and is really striking about the anti-reformers is their cruelty…it has long been obvious that the opposition’s goal is simply to kill reform, never mind the human consequences. We should all be thankful that, for the moment at least, that effort has failed.”
Unfortunately, Obama also failed miserably at framing the issue or at setting the terms of debate after Congress passed the legislation. In fact, his greatest failure was limiting his use of the bully pulpit of the presidency to help Americans understand how their lives improve with universal health coverage.
Anyone in any other industrialized nation would rightfully view all this anxiety about strengthening the safety net with bewilderment. That cruelty is what others should understand when they try to comprehend Americans’ tremendous resistance to universal health care. Thirty million Americans have no medical insurance. They go to emergency rooms for minor illnesses, as well as serious infections or gunshot wounds. They have no primary care doctor and pray that they won’t fall ill or that they won’t lose their employer-paid medical insurance. If you’ve survived cancer or any other “pre-existing condition,” you’ll never get insured again.
The Affordable Care Act has already changed some of these grotesque health inequities. Parents may now keep their children on their insurance until age 26. Pre-existing conditions are no longer an excuse for excluding children from medical insurance. By 2014, no adult will be denied medical insurance because of such pre-existing conditions---—even as minor as a torn rotator cuff, as my stepson discovered.
But Chief Justice Roberts also inserted a poison pill into his decision when he decided to uphold what is called commonly called Obamacare. He argued that the federal government has no right to demand that the states expand Medicaid, which is the second-rate, last resort, medical care for the very poor. With one judicial decision, he upheld the controversial individual mandate that requires everyone to pay for some kind of insurance and, at the same time, he destroyed what Congress had passed, namely, the right of the Federal Government to demand states to expand coverage for the poor.
Like many of my colleagues and friends, I spent the day surfing television stations listening to reporters interviewing people all over the country. “Are you happy about this decision?” they asked. My mouth dropped as I heard one person after another say that the government has no right to force people to pay for medical coverage, even though the government will provide subsidies for those who aren’t poor enough to qualify for Medicaid and can’t afford medical assurance. I didn’t hear one person that day who understood that everyone needed to participate in order to spread the risk of paying for those who fall ill.
Although this is what was shown on television, polls tell a different story. A new Gallup poll reveals that the country is deeply and nearly evenly divided, with 46% of those polled against the Court decision and 46% approving it. Thirty-one percent want the law repealed entirely.
It’s been clear for some time that only half or less of the country has supported health reform. Poll after poll revealed that Americans seemed troubled, unsure what it all meant, how it would affect their lives. Yet, women and some minorities seemed to comprehend the urgent need for universal health care. One poll noted “that 48 percent of women wanted the Supreme Court to uphold Obamacare as opposed to 39 percent of men. Differences in opinion were also present among racial lines, with 63 percent of black Americans backing Obamacare, with 20 percent opposed; and 40 percent of white Americans support the Supreme Court's decision, opposed to 41 percent who do not.”
With the Court decision now settled, the real question is why so many Americans are so troubled by the idea of universal coverage. What is it about American political culture that causes the uninsured, the poor, the ill—the most vulnerable people in the country---to accept the status quo?
The only way to explain this resistance is to really understand that American political culture. First, there is the subterranean fear of socialism and socialized medicine, left over from the Cold War, and never far from American politics. Mark Neumann, a Republican candidate from Wisconsin, responded to the Court’s decision in words that mirrored other right-wing politicians running for office. He said, “Barack Obama and his team" are socialists in every respect of the word."
Second, there is the persistent fear of government- run medicine (which this was never meant to be), fueled by stories about Canada and England, that have convinced people they will wait three years for treatment for cancer. Ironically, this fear persists despite the fact that Medicare—a government-funded single pay health system for those over 65—is wildly popular. At one town meeting, a man shouted, “"Keep your government hands off my Medicare." In a letter to President Obama one woman wrote, 'I don't want government-run health care. I don't want socialized medicine. And don't touch my Medicare.” Persuaded by the right-wing that government can do nothing right, they both failed to realize that the federal government funds this single payer medical care for the elderly.
Third, the poor fear that that they will be forced to pay for insurance they can’t afford. Unaware of the Act’s subsidies to the poor, they fear further expenses if they can currently can get Medicaid for free, which varies by state.
Finally, there is the peculiar atomistic individualism of American political culture that sees itself as Christian but has been reluctant to create a social safety net that reflects those values. This individualism underlies the effective rhetoric used by Republicans and the Tea Party, which insist that health care reform will take away people’s liberty and freedom. Yes, in crisis, we come together, but for the most part, we are not a country that cares about our brothers and sisters. Those who have insurance, want to keep what they have. They are not terribly concerned that the majority of bankruptcies in this country have been caused by people’s inability to pay astronomical healthcare bills that are taken up by collection agencies.
Not everyone, of course is unhappy about the Court’s decision. In addition to health care advocates, national organizations that represent seniors, children and families, even significant sectors of the health care industry, have supported health care reform. The American Medical Association, filled with physicians who once opposed any change, as well as hospital associations, have supported the Act because they know the health care system is falling apart. Even the insurance companies are divided—knowing their profits will be squeezed, but determined to prevent a single payer system.
Obamacare is not perfect. The wealthy will never pay for the quality of healthcare for the poor that they demand for themselves. But for those afraid of losing their “freedom,” new access to health care after 2014 will one day seem like a right, even an entitlement. During the depression, people feared the new unemployment and social security insurance that were passed as part of the New Deal. Over time, these were gradually amended and altered, making them more inclusive. Now Americans take them for granted.
Yes, battles will continue to rage over the Court’s decision. But what has happened is historic. And that will not change unless the country elects Mitt Romney, who has promised to repeal the ACA, in November, 2012.
This essay first appeared in Open Democracy in the UK.