Atul Gawande on Obamacare’s Opponents—How Much Damage Can They Do? Will the Exchanges Open Tomorrow?

Tomorrow, millions of Americans will find out how much healthcare will cost in their state marketplaces as the Exchanges begin enrolling new customers.  On the eve of that event, Dr. Atul Gawande writes about the forces lined up to oppose healthcare reform. The essay, which appears in the newest issue of the New Yorker, quite rightly compares those who are fighting the Affordable Care Act to those who, so many years ago, tried to block the Civil Rights Act.  In each case, conservatives refused to recognize a basic human right.

Gawande is not worried that Republicans will succeed in stopping the Affordable Care Act. Already, the reform is rolling forward on the ground, affecting peoples’ lives. Even if the extreme right wing of the Republican party manages to shut down the government tomorrow, the legislation is largely funded through mandatory appropriations that cannot be curtailed through Congressional  Nevertheless those who are blinded by rage can do great harm.

                                  Who Will Be Hurt? –Paul Sullivan’s Story  

Gawande opens his essay by reminding us of who will suffer—Americans like Paul Sullivan. “Sullivan was in his fifties, college-educated, and ran a successful small business in the Houston area. He owned a house and three cars. Then the local economy fell apart. Business dried up. He had savings, but, like more than a million people today in Harris County, Texas, he didn’t have health insurance. ‘I should have known better,’ he says. When an illness put him in the hospital and his doctor found a precancerous lesion that required treatment, the unaffordable medical bills arrived. He had to sell his cars and, eventually, his house. To his shock, he had to move into a homeless shelter, carrying his belongings in a suitcase wherever he went.”

Under the ACA, this would never happen. His out-of-pocket spending would be capped at $6,350–as long as he signed up for insurance. (If he earned less than $45,650, the cap would be considerably lower.) This is how the legislation helps even those who are too wealthy to qualify for a subsidy. They are protected against financial ruin.

Gawande reminds us that “this week, the centerpiece of the Affordable Care Act, which provides health-insurance coverage to millions of people like Sullivan, is slated to go into effect.” But he observes: “How this will unfold. . .   depends on where you live. Governors and legislatures in about half the states—from California to New York, Minnesota to Maryland—are working faithfully to implement the law with as few glitches as possible. In the other half—Indiana to Texas, Utah to South Carolina—they are working equally faithfully to obstruct its implementation. Still fundamentally in dispute is whether we as a society have a duty to protect people like Paul Sullivan. Not only do conservatives not think so; they seem to see providing that protection as a threat to America itself.”

                           Not Just a Matter of Ideology, a Matter of Values 

Here, Gawande cuts to the heart of the matter. Conservatives simply do not believe that we, as a civilized nation, have a moral obligation to ensure that everyone in this country has access to high quality, affordable care.

As I have explained in in the past, I am reluctant to describe healthcare as a “right.” When people claim something as a “right,” it is too easy to sound shrill and demanding. Then someone comes along to remind us that people who have “rights” also have “responsibilities,” and the next thing you know, we’re off and running in the debate about healthcare as a “right” vs. healthcare as a matter of “individual responsibility.” 

When conservatives and libertarians emphasize “individual responsibilities” they shift the burden to the poorest and sickest among us. The numbers are irrefutable: low-income people die sooner than the rest of us in part because a healthy lifestyle is expensive, and in part because the stress of being poor—and having little control over your life— takes an enormous toll..Republicans who put such emphasis on “individual responsibility” ignore what poverty does to bodies and minds; they are saying, in effect, that low-income families “should learn to take care of themselves.”

Those who oppose Obamacare insist on talking about “individual” rights and “individual” responsibilities; they refuse to think collectively. I would argue that healthcare is not an individual right as defined by the constitution.  It is  what the framers of the Declaration of Independence called an “inalienable human right”– something that we all deserve simply by virtue of being human. Such rights are conferred on us, not be government, but by “our Creator.” 

Those who disagree are, as Gawande points out, bent on  “obstructing” the Affordable Care Act much as those who opposed integration sets out to obstruct the Civil Rights Act: “After the Supreme Court’s ruling in Brown v. Board of Education, in 1954, Virginia shut down schools in Charlottesville, Norfolk, and Warren County rather than accept black children in white schools. When the courts forced the schools to open, the governor followed a number of other Southern states in instituting hurdles such as ‘pupil placement’ reviews, ‘freedom of choice’ plans that provided nothing of the sort, and incessant legal delays. While in some states meaningful progress occurred rapidly, in others it took many years. We face a similar situation with health-care reform.”


In the case of the Affordable Care Act, Gawande explains, “Obstructionism has taken three forms. The first is a refusal by some states to accept federal funds to expand their Medicaid programs. Under the law, the funds cover a hundred per cent of state costs for three years and no less than ninety per cent thereafter. Every calculation shows substantial savings for state budgets and millions more people covered. Nonetheless, twenty-five states are turning down the assistance.”

It is worth noting that in many of those states, an adult does not qualify for Medicaid unless he has children—no matter how poor he is. When Medicaid originally passed Congress, some politicians insisted that only the “worthy poor” should be eligible. (To be worthy, one had to marry and have children.)

But here, I am more hopeful than Gawande. I do not think that it will take “many years” before all 50 states expand Medicaid. Too much money is involved, and the states need the money. This is America. Even in Red States “money talks.” My guess is that by 2015, at least 48 if not 49 states will have taken the federal funding.

Gawande continues: “The second way that Obamacare’ opponents are trying to undermine the law is by refusing to operate a state health exchange that would provide individuals with insurance options. In effect, conservatives are choosing to make Washington set up the insurance market, and then complaining about a government takeover.”

Finally, “the third form of obstructionism is outright sabotage. Conservative groups are campaigning to persuade young people, in particular, that going without insurance is ‘better for you’—advice that no responsible parent would ever give to a child.

“Some states are going further, passing measures to make it difficult for people to enroll. . . . . Tennessee recently adopted an emergency rule declaring that anyone who could be described as an “enrollment assister” must undergo a criminal background check, fingerprinting, and twelve hours of course work. The hurdles would hamper hospital financial counselors in the state—and, by some interpretations, ordinary good Samaritans—from simply helping someone get insurance.”

As a result “in some states, Paul Sullivan’s fate will become rare, “ Gawande observes. “In others, it will remain a reality for an unconscionable number of people. Of some three thousand counties in the nation, a hundred and fourteen account for half of the uninsured. Sixty-two of those counties are in states that have accepted the key elements of Obamacare, including funding to expand Medicaid. Fifty-two are not.

                                            How Long Will the Battle Last?             

“At this point” Gawande acknowledges, “it is becoming clear that the meaning of the plan’s legacy will be fought over not for a few months but for years. Still, state by state, a new norm is coming into being.”

Yes. And as more people begin to understand what Obamacare will mean for their lives, they will embrace that new norm. Beginning in 2014, reality will expose the  fear-mongers’ lies.

Here too, I am  more optimistic than Gawande. I don’t think it will take “years” for the new norm to become the new normal. I would argue that it took so long for many Americans to begin to accept the Civil Rights Act because racism, a canker that has eaten deeply into the national psyche, drove their resistance. Under the Affordable Care Act, white Americans will benefit, along with Americans of many colors. In that way, the Affordable Care Act is more like the legislation that brought us Medicare. It did not take very long for virtually everyone—even Ronald Reagan– to accept a government program that provide universal healthcare for the elderly.

Gawande ends his essay by noting that “Conservatives keep hoping that they can drive the system to collapse. That won’t happen. Enough people, states, and health-care interests are committed to making it work, just as the Massachusetts version has for the past seven years. And people now have a straightforward way to resist the forces of obstruction: sign up for coverage, if they don’t have it, and help others do so as well.”

                                  How You Can Support the Roll-Out 

This is what all of us can do. Explain Obamacare to every young person who you know. Emphasize the free preventive care, including free contraception  the low rates that insurers are charging in the Exchanges,  and the subsidies that, in many cases, will make insurance as affordable as going out for pizza and beer, .

Offer to help older neighbors or relatives who are unemployed, self-employed, uninsured, or under-insured fill out an application to buy insurance in the Exchanges. Stress how much they can benefit from the tax credits that will help cover the cost of premiums.    Urge everyone to apply for a subsidy even if they think they earn a few thousand dollars too much to qualify. Explain that eligibility is based on something called “modified adjusted gross income.”  It’s a tricky number, but your state’s Exchange will do the arithmetic for you to determine whether or not you will receive a subsidy.


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