October 10, 2013.
Political discourse related to naming access to health care as a priority shows expansion to the underserved and needy during the era of the Great Society, when Presidents Kennedy and Johnson expanded the social welfare and services system. During this era, the arguments in support of an economic model to support the government’s role in health and health care extended well beyond the need to keep a work force healthy. They included powerless groups, such as the elderly, who needed government assistance. They also included migrant farmworkers who harvest much of the nation’s food but often lack access to health care. Edward Murrow first exposed the conditions in which these laborers exist in the documentary, “Harvest of Shame.”
My first doctoral student to complete her degree as my advisee told me about her mother’s labors in harvesting the nation’s crops in the fields of California. Her mother died at a young age from cancer likely the result of pesticide exposure during those long hours of harvesting.
From a social justice side, it seems only fair to provide care to the nation’s harvesters of food. When that assertion did not work, evidence that a harvester’s poor health and poor sanitation habits–failure to wash hands, for example–could contaminate the food supply was brought forth. This argument relates to public health and the public good, such that safeguarding the health of those who harvest our food benefits everyone’s health. Too little discussed in conversations about affordable health care are the issues related to public health and the public good.
October 5, 2013
A fourth event shaping the government’s role in naming access to health and care as political priorities was the Great Depression, 1929-1941. Unemployed workers were unable to pay for their own health care. Because so many workers were unemployed, this led providers’ incomes to fall. Middle class citizens began to rely on public hospitals, and state and local health departments to receive health care. In turn, doctors began providing more services through these venues. Doctors charged the welfare departments. State welfare departments in turn charged the federal government. This cost-shifting system was supported by political priorities established in debates at the federal level and then by passage of such policy as the Social Security Act in 1935.
President Truman expanded Social Security and recommended national health insurance in 1949. He continued to work toward it unsuccessfully until 1953, a year before I was born. Nonetheless, an economic model based on commerce as the stimulus to support a government role in health care access made a transition to a government role in health care access for the needy or underserved with the initial stimulus being the unemployed.
September 30, 2013
It didn’t take long for efforts associated with covering costs associated with worker’s health care to become burdensome. In 1927, the Congressional Committee on Costs of Medical Care proposed Health Maintenance Organizations [HMOs] as a strategy aimed at providing affordable health care to all citizens. A minority report written by doctors and adopted by the American Medical Association, however, took the position that HMOs would hurt the quality of health care. As a result, the Committee’s recommendation was not seriously considered.
Congress initiated a program for its own health care in 1928. In response to a number of elected lawmakers collapsing and even dying while on duty that year, Congress asked the Navy to provide a physician for the Capitol. The Office of the Attending Physician provides some basic care to members at a cost of about $500 a year, the same rate that has been in place since 1992. The budget for the Office of the Attending Physician is more than $3 million [http://thomas.loc.gov/cgi-bin/cpquery/?&sid=cp113l8f0T&r_n=hr173.113&dbname=cp113&&sel=TOC_22349]. There are several Navy doctors providing the care, together with more than a dozen registered nurses. The budget also includes a pharmacist, an ambulance available at the steps of the Capitol building, plus first-aid stations that staff members may use, and the x-ray and lab equipment available for care. In addition, care for families of Congress comprises choices much like all of us must make [http://jeffduncan.house.gov/legislative-work/fact-or-fiction/fact-or-fiction-do-members-congress-get-free-health-care].
September 25, 2013
In the first two decades of the 20th century, middle class progressives realized that the American industrial society’s working-class citizens suffered ill health and injury through no fault of their own. Work places were often unsafe, causing injury to workers and their ability to work. In recognition of these facts, a number of economists formed the American Association for Labor Legislation (AALL) in 1905 for the purpose of studying labor conditions and labor legislation [see http://www.proquest.com/en-US/catalogs/collections/detail/American-Association-for-Labor-Legislation-38.shtml].
The AALL group advocated for health reforms in industry and sought compulsory health insurance. Initial efforts to argue the merits of such legislation focused on workmen’s compensation. This strategy aimed to provide access to care for workers injured on the job.
Woodrow Wilson joined the AALL [http://www.ssa.gov/history/corningchap1.html]. He included their social insurance plank in the 1912 Progressive party’s platform. In 1915, the AALL published a model health insurance bill in legislative language to be considered by State legislatures, with California, Massachusetts, and New Jersey supporting the proposal out of the 12 States that discussed it. As debate continued within the States, so did opposition to a proposal for government health insurance. AALL leaders assumed that such reform would be viewed as beneficial to all. The stage was set for health insurance to dominate conversations about health care.
September 20, 2013
Other early federal debates led to the provision of health care to the armed forces, naming the public good and satisfaction of economic aims to support the government’s role. It was argued that a healthy army and navy were necessary for national defense. The patchwork of care for the U.S. military covers decisions relating to those who serve, have served, and their families [see http://usmilitary.about.com/cs/healthcare/a/medicalcare_4.htm for a summary]. Lost in the conversation about the uninsured and the Affordable Care Act is the data about our nation’s veterans. They comprise a very large group of the uninsured. Here is the estimate from the Robert Wood Johnson Foundation: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/03/uninsured-veterans-and-family-members.html — 1.3 million veterans plus their families [about another 1 million] have no access to health care.
How does the Affordable Care Act affect military families? An analysis that includes comparisons between Tricare and ACA requirements appears at: http://www.militarytimes.com/article/20130926/BENEFITS06/309260025/Affordable-Care-Act-No-impact-Tricare-some-coverage-isn-t-equal. It appears that the ACA will require more coverage than Tricare offers in various instances.
As for veterans and their families, if their income levels fall within Medicaid guidelines, they may receive care through an ACA Medicaid-expansion option. That depends upon their State’s buy-in, however, so it remains unclear whether this group of hundreds of thousands will find a path to care or not.
September 15, 2013
As President Obama took on the health care issue, his overall aim appeared to be to address access to health care for those who do not have it. This includes some of our most vulnerable citizens, ranging from children living in poverty to the elderly who lack the resources for care. This President, as others before him, sought to promote the dignity of citizens through the provision of health care and to exercise social justice in ways that represent ideals expressed in the Declaration of Independence—promoting “life, liberty, and the pursuit of happiness.”
The U.S. Constitution, which was adopted in 1787 as the supreme law of the newly formed national government for the thirteen states, does not endow Americans with a protected right to health care. This was a conclusion reached by the U.S. Supreme Court but one that finds itself at odds with other republics where a level of health and health care are explicitly guaranteed [see Poland, for example—p. 3 of http://www.ehma.org/files/Benefit_Report_Poland.pdf].
The reasons for an absence of reference to health and health care in the U.S. Constitution likely reflect both the desire to avoid government intervention—related to the very foundation leading to the formation of this nation–and the practical reality that medicine was in its infancy at that time. Thus, there was not much anyone, let alone government, could do to promote the health of individuals. Family comprised the primary unit of both social and economic life, and family assumed the role of caring for sick and injured members.
Very early on, these realities conflicted with the fact that merchant seamen, who acted on behalf of the welfare of all U.S. citizens, became ill and/or disabled in the performance of their duties. Thus, it was only “just” to pay for their health care. In accord with this premise, Congress passed an act to provide for merchant seamen’s medical care in 1798. Congress used the authority of Article I, Section 8 of the U.S. Constitution to support this policy. It empowers the federal government to regulate commerce with foreign nations and to tax for the general welfare as a means to that end. The health and well-being of individual seamen was not the argument used to support a role for government in providing health care. The need for a government role in health and health care resided in a focus on promoting commerce. Government efforts to provide health care, however, were squarely on the table, beginning a path toward where we are today.
September 10, 2013
Nothing I enjoy more than a walk along a creek or stream and gathering fall foliage. In this case, it is cattails. A great way to spend a birthday.
At the same time, an announcement came into my email about the approval of 114 million dollars to support patient-centered outcomes research. The Affordable Care Act introduced this new research institute as part of its overall mission. Each of us will contribute one dollar to the initiative as part of the plan to fund its activities. I am not yet sure why a new institute was needed in addition to the National Institutes of Health which often includes patient centered outcomes research. I haven’t heard any real public discussion about this new initiative to fund research. You can check it out here: http://www.pcori.org/about-us/how-were-funded/
I will continue to ponder the meaning of another institute as part of the Affordable Care Act and share any insights I gain. Please do the same.
September 6, 2013
The news often tells us something about the quality of our food. It may be a story about salmonella and chicken. Or it may be about a recall based on something being in a food that should not be there–perhaps due to defective equipment in a processing plant or two foods getting mixed together or peanuts being present when they should not have been. These stories help us select healthy food and should make us realize how much is done to keep our food safe. One of the more recent policies relating to our food safety is explained at http://www.fda.gov/Food/GuidanceRegulation/FSMA/ucm247559.htm and makes clear that illness from food remains a big problem. With one in six of us becoming ill from foodborne illness, more than 120,000 hospitalizations, and about 3,000 deaths each year–we should all be aware of what we can do to stay safe and what the modernization act does to make it more likely.
August 28, 2013
One of the fun things about writing a book like ‘Talking about health’ is that readers tell me that they are inspired by the family stories included in the book. My youngest sister includes her story about a long road to conceiving her daughter–both pictured here with popsicle stick in hand.
I have read many of the stories in my book to my undergraduates and they, like some readers who have told me what they like about the book, love my sister’s story. Perhaps many can relate because they know someone who has gone through something similar [see http://www.cdc.gov/nchs/fastats/fertile.htm for CDC statistics about just how many].
Today is my sister’s birthday. I wish we lived closer so that we could have shared a cup of peach green tea. ‘Happy Birthday, Sis!’
August 23, 2013
Well, the annual check-up was mostly good news. My numbers were mostly good. 64 resting pulse. 120 over 78 for blood pressure. But then my doctor said, “Don’t you like fruit?” Huh?
“Your potassium is low. Don’t you like fruit?” I eat an apple almost every day, I say. He nods and says, “Eat more fruit.” OK. What kind? How much?
First, potassium–why is it important? I guess I could’ve asked but it seemed as if I was expected to know. And I knew I could find out online. Which I did. Let’s just say that potassium is very important. It is crucial for heart function and for muscle contraction.
There are lots of food sources of potassium but I did find a ‘top 10′ list of fruits at http://www.healthaliciousness.com/articles/high-potassium-fruits.php. Dried apricots are number 1 and bananas are on the list but much closer to the bottom. Prunes, raisins, dates, and figs are on the list as well. I guess I will try a little harder to get some more of these in my daily routine.