Of stars and proper alignment: scanning the heavens for the future of health care reform.

• Author: Rosoff, Arnold J.

INTRODUCTION I. ECONOMICS II. POLITICS III. HISTORY IV. INFRASTRUCTURE V. DEMOGRAPHICS VI. NATIONAL CHARACTER CONCLUSION INTRODUCTION

On March 23, 2010, the United States took a giant step toward achieving universal health care, an elusive goal it has pursued for almost a century. The legislative fight was bitter and divisive, pitting Republicans against Democrats. It revealed, as effectively as any issue in recent years has, how difficult it is to achieve bipartisan cooperation when tackling America's biggest problems. Nonetheless, the product of that contest, the Patient Protection and Affordable Care Act (1)--referred to herein as the Affordable Care Act, the Act, or, as its detractors call it, "Obamacare"--fed the hopes of many Americans that we could finally come to recognize an adequate level of health care as a right of all our citizens and thus shake the dubious distinction the United States has long held of being the only major, industrialized nation on earth that has not committed to this noble goal. (2)

But as this is written, in March 2011, the Affordable Care Act's future, and the future of health care reform more broadly, is far from certain. Two federal district courts have ruled that what many regard as the Act's keystone provision, the individual mandate to purchase health insurance, (3) is unconstitutional. (4) The first court concluded that the offending provision can be excised from the law and the remainder left intact; (5) the second held that the provision is so integral to the overall legislative scheme that the entire law must fail. (6) Since three other district courts have already rejected challenges to the Act's constitutionality, (7) it is virtually certain that the Supreme Court will ultimately review the Act. If the case takes the traditional route through the courts of appeals, then it should reach the Supreme Court around the time of the national elections in November 2012. (8) On a parallel track, the newly installed 112th Congress has begun to consider a repeal of the law. (9) Despite the formidable obstacles that a repeal attempt would have to overcome--unlikely passage in the Senate (10) and a likely presidential veto--the winds of opposition are blowing so strongly that a repeal is at least within the realm of possibility. Setting aside these challenges and assuming the Affordable Care Act survives, it is an open question whether the Act can deliver on its very ambitious promise to secure basic health care coverage for almost our entire population (11) without bankrupting the nation's health care financing system or reducing the quality of care those who are now covered enjoy. Clearly the road to universal health care is a difficult one for the United States. Like previous trips, this one may again prove to be a road to nowhere. (12)

What is it that makes the United States so different in regard to universal health care? Why have other nations been able to make the commitment while we, despite our impressive wealth and high social ideals, have not been able to get there? Some five years ago, before the current health care reform contest got underway, I undertook a study of five other nations around the world--Argentina, France, Italy, Singapore, and Japan--to understand how each came to commit to universal health care. For reasons both obvious and not, this is a commitment of the greatest magnitude and seriousness, one from which retreat is close to impossible; thus it is a commitment not to be made lightly. It is a commitment the United States has not been able--or at least not willing--to make despite numerous attempts. (13) Some--including President Obama as he campaigned for health care reform--have said that the stars have to be in proper alignment for a nation to commit to universal health care. (14) So I set out in 2005 to discover what the "stars" are and what "proper alignment" would look like--in other words, what are the factors and elements that have to be in place in a nation for it to undertake the monumental commitment to assure that all its citizens have an adequate level of health care? My starry-eyed goal was to help the United States figure out how to get its stars aligned and finally take the plunge. I hoped that my insights might feed into the policy process and help the proponents of health care reform devise an approach and strategy that would make their campaign more effective and, ultimately, successful.

My work has taken place through an interesting and eventful period in U.S. history, one that health policy commentators, and historians generally, will be dissecting for years, perhaps decades, to come. It has seen Hillary Clinton, whom many regarded as the front-runner to secure the Democratic nomination in the 2008 presidential race, pass the baton to Barack Obama. In that shift, many liberals gradually reset their dreams, sometimes with great difficulty, from wanting to see history made by electing the first female President of the United States to instead electing the first black President. It has seen Ted Kennedy, "the lion of the Senate," who carried the torch of universal health care for decades, pass from the scene with a final, impassioned, noble push for his dream. (15) And at the end of the contentious debates discussed above, this period has seen the most significant and far-reaching health care reforms since the passage of Medicare and Medicaid almost half a century ago, But to use the language of the so-called "Chinese curse," (16) the "interesting times" are far from over. Obamacare is squarely in the Republicans' crosshairs, and Congress has joined the battle. The game is still on!

The primary objective of this Article remains basically the same as when I started my research: to set out my observations about what the "stars" and their "proper alignment" are, to provide a framework for understanding the factors that go into a nation's decision to commit to universal health care and ultimately, to better understand America's prospects for finally achieving universal health care. The context for my work, however, has changed, and changed again. I originally hoped my work might help lead to the passage of health care reform. When the Affordable Care Act was enacted, I reset my objective to offering an analysis of how we achieved this historic social goal. Now, with the Act under intense fire, my objective has shifted again, to offering a perspective that can be used to defend the tenuous gains made in 2010 and help our nation sustain the commitment it has made to the lofty goal of health care for all Americans.

What are the "stars"--the key factors that set the context for a nation's movement toward providing universal health care? In my view, there are six factors, not mutually exclusive; they overlap and interact substantially. They are: economics, politics, history, infrastructure, demographics, and national character. A brief overview of each follows.

1. ECONOMICS

   What is required of a nation's economic situation in order to seriously contemplate the commitment to universal health care? Health care for all can be an expensive proposition and it is a commitment that, once made, must be maintained in both good times and bad. One might expect, then, that a nation would choose to shoulder this burden only when its economic situation is sound and the nation has been in that enviable position long enough to feel that prosperity is a steady state--a sustainable future reality. Looking at the United States' own history supports such a theory.

   Medicare and Medicaid were passed in 1965 (17) after almost two decades of relatively unbroken post-World War II prosperity. When President Lyndon Johnson called on the nation to commit to providing mainstream health care for the elderly (Medicare) and the poor (Medicaid), he was not asking Americans to reach into their pockets and give up some of their limited funds to help support the less fortunate. Rather, he was saying, in effect, "If history holds, next year will be better than this year. I'm asking you to commit a portion of next year's incremental gain so that the most vulnerable of our citizens are assured a decent standard of health care services. It is the least a nation as wealthy as ours can do." (18) If one draws from this statement that Americans will commit to social equity programs only when they are feeling prosperous--and when they have felt that way for long enough that their memory of less fortunate times is dim--then it is unlikely the United States will make a sustainable commitment to universal health care in the foreseeable future. Indeed, one could infer that the peril in which the Affordable Care Act currently finds itself is largely attributable to Americans' fears about their economic future. (19)

   But prosperity is not historically a sine qua non for commitment to social advances; many nations around the world made their commitment to universal health care in times of economic distress. Perhaps most notably, the British launched their National Health Service (NHS) shortly after the end of World War II. (20) Their economy was weak and British cities were in dire need of rebuilding after years of wartime bombing. Sir William Beveridge, lead author of the famed "Beveridge Report" on social services in Britain, (21) was asked how the country could possibly afford to provide health care for all when its financial situation was so shaky and so much work needed to be done to reduce the wartime debt. His answer essentially was, "how can we possibly afford not to?" (22) The work of rebuilding a devastated nation and economy takes strong citizens. Beveridge argued that the productivity gains that would flow from having a system of national health care would more than offset the costs of establishing and maintaining that system. (23) It was a leap of faith argument, one that could not be tested until it was tried; in fact, it is not clear that Beveridge's argument was...