Unaffordable Care Acts

With the installation of yet another “originalist” Supreme Court Justice, the Affordable Care Act is doomed. Most people refer to this legislation as Obamacare. It provided some health insurance coverage for at least 20 million Americans who had little or no insurance.  It forced coverage of pre-existing illnesses and allowed people with children needing insurance to get that coverage under their own policies until the child was 26 years old. It involved many other benefits. Consequently, it needed to be killed before Americans got too comfortable with the benefits it provided. One senator (Ted Cruz) actually said as much.

As an American, I am saddened. As a physician, I am appalled; but the law is the law. The Supreme Court will review the law and decide if the framers of the Constitution wrote language that supported the largesse contained within the Affordable Care Act. This Court will decide if a committee of men from the eighteenth century who had no knowledge of the germ theory of disease or the basis for epidemics or the origins of fevers or the importance of blood flow created a document supporting the Affordable Care Act.  This “originalist” Court may argue that the Constitution had built into it the mechanism for amendments whenever an update was needed, but the past two centuries have demonstrated the lameness of this mechanism.

That Congress agreed on the Affordable Care Act was nothing short of miraculous. That efforts to eliminate it through court actions without having any measures already in place to provide health insurance for the millions who will be affected is nothing short of inhumane. Those who had health care while this Act survived may soon die off, and few will question the wisdom of those who stomped it to death. After all, who remembers Justice Taney’s repudiation of freedom for escaped or relocated slaves in the Supreme Court decision on Dred Scott v. Sandford? That decision set in motion events culminating in the American Civil War.

I certainly do not believe that this decision will lead to civil war, but it will cause immeasurable suffering. Just 1 week ago a friend sent me a picture of her sister-in-law’s lacerated fingers. The injured woman had been moving a refrigerator and sliced her fingers on a ragged piece of metal. My friend, Harriet, asked what her relative should do about this injury. I thought this was a ludicrous question, but years of dealing with the ill and injured had taught me that logic was always the first casualty of trauma.

You cannot be expected to be rational when you or someone you care about is sick or injured. I told Harriet that she needed to take her sister-in-law to an emergency room, get the laceration cleaned and sutured, get a tetanus shot, and find a hand surgery to follow-up with if one was not available at the nearest hospital emergency room. Harriet stopped me before I could elaborate on my advice and announced, “She has no insurance.”

Before the Affordable Care Act, this simple statement often punctuated conversations I had with patients. After the Act got up and running, this refrain seemed to have died off or least been muted, Harriet and I discussed strategies to get around this problem, but in the end someone had to come up with a substantial chunk of change to keep this woman from dying of tetanus or losing her fingers. 

Some will say this woman was careless not to have planned for this misfortune. Actually, planning would not have helped since she had no savings, could not get coverage through her employer and was not covered by someone else’s insurance. She did not know how to get health insurance under Obamacare. Now, she will be just one of the tens of millions of Americans who cannot afford or cannot acquire coverage for healthcare. She will no longer be an anomaly.

“Why should we care if some people cannot get health care?” you might ask.  “Why should we care if people from outside the U.S. who are here legally or illegally cannot get health care?” The answer is best summed up by a familiar name: Typhoid Mary. The woman so named was actually a cook, Mary Mallon, who unknowingly infected more than 50 people with typhoid fever. She carried the germ that causes typhoid fever but had no symptoms associated with it (sounds like Covid-19, doesn’t it?).

All the people she infected suffered terrible consequences. Some of the infected died. Wherever she worked, she inadvertently contaminated the food she prepared with the typhoid germ that she carried and to which she was resistant. Even though this occurred more than a century ago, the epidemic was contained with contact tracing and ultimately isolation of the infectious woman. She was not imprisoned, but she was never allowed to cook for anyone except herself.

Not providing health care to anyone in society has an impact on everyone in society.  You do not want people with infections going untreated. You do not want someone with a finger laceration to develop symptoms of tetanus while driving a car. That person sweeping your steps or doing your taxes needs to get treated for infections, trauma, or other health problems that can directly or indirectly affect you or those you care about.

People generally do not come to the U.S. to get health care.  If it is widely available in a country, as it is in several European countries, you do not find people crossing borders to see doctors. They move from their homes to get work, avoid war or famine, escape persecution or for a variety of other reasons, but getting free or cheap health care rarely makes the list.

I worked and lived in Germany for several months.  Their health insurance system is best described as Medicare for all.  The government is the single payor. Insurance companies negotiate with the government to establish uniform coverage and costs. It works.

I do not understand what is the objection to universal health care coverage. When people in our communities get sick or injured, we all end up paying a price.  Denying health care to a sizable portion of society does not make health care less expensive for those who still have access to it. The healthier we can keep ourselves, our neighbors, our friends, etc. the less we end up paying in the long run.  With Covid-19 we have gotten a harsh reminder of what it actually costs in terms of income and productivity, in terms of childcare and education, in terms of freedom and leisure travel when our health care system does not accomplish the result we expect it to achieve.

The U.S. has one of the most expensive health care systems in the world, and despite assurances from our politicians, it is not anywhere near the best. We are paying for Cadillacs and getting Volkswagens.  It is a system with many deficiencies.  Eliminating the Affordable Care Act will add to those deficiencies.

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