Category: Blog

In “Uninsured in America,” Susan Starr Sered and Rushika Fernandopulle attempt to find out “where the bodies are buried” in our health care system where over 45 million people have no insurance. The book is a patchwork of profiles of people who got sick at times when they lacked insurance and the often devastating effects this had on their lives. The authors, who describe this phenomenon as the “death spiral,” don’t find so many bodies buried (although they do find many in jails or on the street) but they do find health problems that are allowed to become critical before state assistance will kick in and doctors actually pay attention, and emergency rooms used as primary care resulting in crippling debts.

Without getting bogged down in dry facts and figures, the authors provide a pretty good understanding of how the number of uninsured Americans hides how many Americans are functionally uninsured, covered by plans that have expensive premiums, deductibles and co-pays, that refuse to pay for the very “pre-existing conditions” that people most need health care for and slipping in and out of the patchwork system of Medicaid, charity, clinics and emergency rooms.

The book reminds me of an experience working for the health care workers union, doing community organizing among poor souls on Long Island whose medical debts were referred to collection agencies. Although the non-profit hospital where they went to the emergency room was required by law to provide a certain amount of charity care, these patients were never informed of the option to apply for the charity. Instead they were treated, charged tens of thousands of dollars that they could not possibly afford and had their lives turned into nightmares of bill collectors, bankruptcy and foreclosure. One family actually had good health insurance won through a union contract, but a bureaucratic error at the hospital resulted in the patient – not the insurance company – being billed. The insurance company and the hospital fought, refusing to admit error, and the hospital simply referred the matter to a collection agency. The rest of the people had no insurance. A surprising number of them had children with asthma who had bad attacks that required a visit to the emergency room. Just like that, the family became poor.

This patchwork system results in poor health care for all of us, I think. I hate going to the doctor with any kind of health complaint. I never get any kind of satisfying diagnosis. Usually, the doctor just guesses at a diagnosis and prescribes some kind of medication, without running any tests, and there’s no follow-up. I think the paperwork and bureaucracy is too much of a hassle. Fortunately for me, if my doctors miss something big, the care will be paid for by insurance so I won’t have to wait until I get so poor and so near-death that the state will finally pick up the bill, like the people profiled in “Uninsured in America.” Of course, why would I really want to push for tests that would confirm a medical condition, if that will only be used against me in seeking insurance in the future?

The United States has the best health care that money can buy, provided one has the money to buy it. Jill Quadagno’s “One Nation Uninsured” answers the question “Why the U.S. has no national health insurance.” It’s a brisk, engaging read that neatly summarizes how 90 years of failed reform efforts have entrenched the powerful interests that profit from the system.

The most prominent early opponents of a national health service were the doctors themselves. Their lobby, the American Medical Association, fought against “socialized medicine” out of fear that it would lead doctors to lose their sovereignty to bureaucrats basing decisions on budgetary needs rather than medical needs. Allied with southern politicians who feared that a federal health system would force racial integration of hospitals, these forces successfully kept national health care out of Roosevelt’s original Social Security legislation. They favored market solutions like Blue Cross and commercial insurance. A new business was created, resulting in a more powerful lobby.

The trade union leaders of the time, many of whom were social democratic in their outlook, reluctantly shifted their efforts at creating a social safety net to the bargaining table, winning employer-sponsored health care plans. Some unions – notably Sidney Hillman’s Amalgamated Clothing Workers – created their own networks of health care clinics, socialized medicine in miniature. Wartime government policies that encouraged fringe benefits over wage increases greatly expanded the private welfare state so that by the 1950’s, most large employers (including non-union firms that aimed to remain non-union) provided health care benefits.

Trade unions continued to push for a government solution to health care, but by the 1960’s they narrowed their focus to the proverbial “camel’s nose under the tent,” health insurance for the nation’s elderly. The Medicare program that the coalition of labor and seniors won had several unintended consequences. One was that with senior citizens covered through the program, and most working families fully covered by an employer’s plan, few voters clamored for a universal national health care system for the next few decades. Another consequence, happily, was the racial integration of most hospitals, under threat of being denied Medicare funding.

A regrettable consequence of Medicare was rampant inflation of cost of health care. Doctors and hospitals provided comprehensive care for senior citizens, ordering tests, procedures and drugs that they might not have before there was guaranteed funding, which was a boon not only to the health of senior citizens but to the corporate bottom line of the for-profit hospitals and insurance companies that joined the market for health care services. The cost of Medicare skyrocketed, until government efforts to control costs caused insurance companies to simply pass on the costs to employers in the form of higher premiums for their employees. Companies responded in turn by cutting benefits, introducing co-pays and turning to health maintenance organizations to control costs by denying care. The doctors’ worst fear, losing sovereignty over medical decisions, was realized through the insurance companies that they were responsible for creating.

This brings us to our current circle of hell, where an employer’s threat to cut benefits leaves many unions close to helpless in contract negotiations, where people with the dreaded “pre-existing condition” are denied meaningful coverage and where the existence (or non-existence) of national health care or employer-sponsored insurance goes a long way towards determining a company’s competitiveness in the global economy.

This January, I’ll be taking an elective class with Dean Robinson that will be exploring the United States’ lack of a national health service and its impact on our health, wealth and democracy. Quadagno’s “One Nation Uninsured” is the first book assigned. Others are Kawachi and Kennedy’s “Health of Nations: Why Inequality Is harmful to Your Health” and Sered and Fernandopulle’s “Uninsured in America.” For my paper, I will be taking a look at some trade union health clinics, particularly the Amalgamated’s (now UNITE HERE) and the NY Hotel Trades Council’s, which was inspired by Hillman’s example. These socialized medicine-in-miniature not only provide comprehensive health services, but they keep costs so low that employers actually offer up concessions in order to take part.

The lesson here, I think, is that while we might succeed in creating a single-payer health care system like Canada’s (particularly as health care becomes more of a crisis), inflation and price-gouging will be crippling until we take the profit out of the system and nationalize health care services to serve the interests of the people, not the corporations.