Dear President-Elect Biden,
Congratulations on your campaign and your successful election. The grace and integrity you modeled during this pivotal election, the humanity you displayed at every turn, and the hope you proffer are sorely needed in our nation today.
Another thing we sorely need is a reexamination of what the health of our nation means. Are we simply referring to a broken health care system that provides different levels of care based on geographic location and economic status? Do we refer to the strangle-hold of restrictive networks that determine who will receive the best care and who will receive mediocre services, if any at all? Do we refer to the finally acknowledged scourge of endemic racism in our health care system? Do we, as a nation, believe in being able to live a life of respect and dignity, or are we okay with too many of our friends, neighbors, and families having to scramble to make a living — working multiple jobs just to maintain a roof over our heads, food on the table, and basic necessities for our family?
The fact is, too many of our neighbors must focus too much of their lives on simply surviving. This precludes many of us from being full participants in our society. If all of one’s energy is focused simply on surviving day to day, what energy is left to pay attention to what is going on all around us? This is not a new phenomenon in our country, nor in human history. Forcing the majority of the country to spend their time merely surviving allows those in power to do as they will. Those who have been called variously lords, robber-barons, the wealthy, the 1%, have free reign to make decisions that will benefit themselves instead of working toward a better society for all.
Throughout history, we have seen that when more people have access to true prosperity — the ability to earn a living wage, to have time left at the end of the day to join in with neighbors and friends in social activities, to spend quality time with family, and to not constantly worry about how far their next paycheck will extend, the happier and more prosperous the society. That means those at the top of the socioeconomic ladder benefit along with the rest of the population.
But we, as a nation, have strayed from that path. One of the reasons people romanticize the 1950’s is that for many — but by no means all — it was a time of prosperity, comfort, and security. Due to social contracts laid down 20 years prior, we saw more people able to work good-paying jobs, have a home, and send their kids to quality schools that taught critical thinking, civics and humanities. People had time and energy to create and maintain relationships with their communities, and people had access to health care that would not put them in the poor house.
As the disparities among our cubby-holed society began to be more evident — as fully half our country began to demand the same type of life that many envision when we talk about the idyllic suburban life of the 1950s and was portrayed so romantically on the big and small screens, we allowed those who wanted to maintain the status quo — who feared being less than or equal to those we have, from our founding, decided were less than human — to keep dividing and separating our fellow citizens. There were many advances made in the 1960s, but also many missteps and critical errors made. Those who do not take the central teaching of most religious creeds to heart — that we are all made in a deity’s image or that we are all children of Man and none is higher than the other — fought back believing that equity is a pie that is diminished by allowing others a part of it instead of seeing it as a banquet to which all bring more flavor and experience.
We saw communities come together to provide that which they were shut out from — stable housing, access to food, education, reading programs, voter registration, medical care, and even protection from persecution. For too many, this could not stand, and groups like the Black Panthers were vilified and ground down yet again.
We saw the rise once more of those who profit from suffering. A sad remnant of those who profited from the perversity that is slavery gained more and more leverage and power to pursue their goals: profit above all and workers as simply a means to an end for the altar of wealth and power with bigger platforms and more money to influence elected officials.
We saw the institution of for-profit medical care. We saw the monetization of our neighbors’ suffering. We saw articles describing the values of the elements that make up the human body say the total was about $600 seemingly taken as a challenge by those for whom shareholders’ gains rule everything. We began a path forward that exponentially exploited the vagaries of the human body and the things that can go wrong with it to benefit the bottom line of those who saw suffering as potential profit.
As a nation we continued to listen to some elected leaders and influencers and allowed ourselves to believe that instead of us being part of a greater whole, all that matters is what we as individuals could get as quickly as possible. How far we could rise up the corporate ladder no matter who we stepped on to get there. How many shiny objects we could obtain, and if they break, throw them out and get more. We began to believe that the economy really was the Dow Jones report and the stock market and if it was going up, even as wages stagnated and in too many cases began to decline, all was well.
Later we allowed the national tragedy of 9/11 to further erode our rights and allow those who sow dissension in pursuit of their own power to further divide us. They insisted we believe that there were those among us who were ‘others’ and not like us. No more were we the Great Melting Pot that celebrated the different ingredients that those from other countries, cultures, religions brought to our shores and made a more glorious whole. No — we stopped trusting anyone who was different no matter how small the difference. We allowed tribalism to exceed citizenship, stopped actively teaching our children how to think critically because all that mattered was how well they tested and toed the line.
We vilified those who had the audacity to stand up and say this was not right until finally, many of the nation said this is enough, and elected a new leader who reflected that idea. With the new direction of leadership under President Obama, we finally saw changes to move us as a nation forward. Not all the way by any means, but a beginning.
With that administration, we saw the blossoming of the belief that health care is a human right. That people should not go bankrupt trying to overcome illness, or trying to afford medication for chronic conditions. That insurance companies should not be able to use a person’s medical history to determine if they will be covered. That the insurance industry could not charge women more for the same coverage simply because they are women and no longer would pregnancy be labeled a ‘pre-existing condition.’ No longer would insurance companies be able to limit the benefits people have paid for on an annual or lifetime limit. No longer could insurance companies retroactively cancel an insurance plan when one got sick. No longer would the intrinsic value of a human life be subject to the same vagaries, repackaging, and monetary manipulation as the mortgage industry utilized prior to the Great Recession — or so we thought.
That was the goal. Even then, we saw the country divided horrifically. But through perseverance, determination, and yes, compromise, the Patient Protection and Affordable Care Act was finally passed. It was by no means perfect. There was a much more comprehensive bill in the House that would have addressed many of the issues we have discovered over the past 10 years with the final bill. But at last our country as a society and our lawmakers had taken the next step forward to join other nations around the globe in the truth that health care is a human right.
No, it was not perfect. Much of the law was predicated on letting the market determine prices and how competition would prevail. The initial goal of a public option was scrapped. Letting the market determine pricing for premiums, deductibles, hospital and medical fees, and more, saw health care go from being 1/6th of our nation’s economy to 1/5th in the space of 2 years. But it was not meant to be perfect. It was meant to be the next step on the path laid down by President Roosevelt, and later President Johnson. The path toward a more equitable society.
There are many things that need to be improved, which have come to light the past 10 years. Things like the family glitch — if a family member has access to health care through their employer, their family must use that insurance and not the exchanges, regardless of whether it is affordable for the family. The ‘fiscal cliff’ which is the cut off for federal subsidies for those enrolling on the exchange, which has priced many Americans, especially older ones and those within tens of dollars of the cut-off limit, out of the exchanges and access to health care. The lack of choice of insurance carriers in some counties across the country has limited the loudly championed idea of competition. It is hard to trumpet the benefits of market competition when there is no competition to bring down prices.
The continued purchase and consolidation of medical providers — especially the influx of private equity firms who see health care as an easy profit market and have no care for the people seeking treatment and help — have led to persistent decline in affordability and accessibility in health care. The purchase and closing of hospitals, especially rural hospitals and those in low-income communities of color, have reduced the availability of care to too many across the nation. The continued idea that health care is not a right, but a commodity to be exploited is further dooming our population. The ACA’s passage saw a decline in medical bankruptcy, but those numbers are climbing again. The implementation of PBMs (Pharmacy Benefit Managers), initially touted as a way to reduce the cost of prescription drugs, has led to further layers of bureaucracy and less ability of physicians to ensure their patients can receive the medications that have been prescribed.
When the ACA was passed, you famously said this was a “Big F-ing Deal.” You were oh so right. Now is the time — past time frankly — for the next step. Too much of the law’s implementation is dependent on who the administration is and who is put in place as Secretary of Health and Human Services. Many fixes have been passed by the House, yet blocked by the Senate. Executive Actions have been used by the current administration to whittle away what could not pass Congress. Civil rights protections for the LGBTQ+ community, immigrants, women, and other minorities have been curtailed. Advertising for Open Enrollment and educational services to help people get covered have been slashed. Too many in this country live in states whose lawmakers chose spite over the well-being of their residents and refused to expand Medicaid.
But the health care of the nation cannot be seen as a piecemeal issue. We cannot afford as a nation to continue to compartmentalize what constitutes equitable health. Just as our medical system has become more and more focused on specialities of different systems in the human body — essentially ignoring the whole for the sum of its parts — so has our society and government compartmentalized what a healthy member of our society needs.
It is more than access to an affordable health insurance plan, it is more the metal levels on the exchanges. It must include access for all residents to affordable, comprehensive, quality health care as needed and available locally. It must also include food security, affordable quality housing, real education for all, family leave protections, living wages, affordable comprehensive childcare, and affordable higher education. It means severing insurance from employment and making it available to all — regardless of whether they work for a large employer or have their own start-up. This need not mean an attack on unions and what they have striven for — their very successes could serve as a baseline going forward. It must mean that those in rural areas and those without access to transportation are as equitably served as those in wealthy urban areas. It must mean that medical professionals are permitted to treat their patients and not have to beg an insurer who has never met the patient to approve the care needed. It means insurers cannot require the prescription of medications that do not meet the need simply because of cost. And it must include the Congress passing an expansion of medical residency openings at hospitals across our country, especially in a time of an international pandemic.
Further it means a review of our patent law system, and a review and modification of our monopoly laws. It means making broadband access available across the country, and it means making the COVID-19 vaccines — all of them — available free of charge and taking the vaccines to the populations who may not be able to travel to receive them. It means an embrasure of the idea that #OurHealthIsNoOnesCommodity.
It means the demilitarization of our police system, the end of the idea that people in power — be it law enforcement, corporations, or everyday citizens — have the right to take or endanger the lives of fellow citizens with impunity. It means that workers’ rights are more important than shareholders’ stakes and corporate compensation plans. It means embracing the idea that melanin is not a determinant of the worth or value of a life. It means taking to heart that faith, national origin, primary language, and ancestry do not determine one’s predetermined place in society. It means addressing the institutional racism of our justice system, and ending the idea of for-profit prisons and the inherent oppression this process engenders and promotes.
No one person can achieve all of this. Indeed no one leader should. But a strong, successful leader can start us back down the path to an equitable nation. There are millions of Americans waiting to help, both at the legislative and grassroots level. Guide us, let us know what you need. Listen to us who have been in the trenches and have lived with the positives and negatives of the original ACA. We know perfection is rarely obtained. We know that real solid compromise means that while all sides are somewhat unhappy, progress has been made. Together, we can move our country forward toward a more perfect union and improve the physical, emotional, and societal health of our nation.
Originally posted on Medium
ACA Consumer Advocacy
This blog contains thoughts and observations about health care and the ACA in the United States.