It may be tempting to get caught up in cynical views of congressional lawmaking, budgeting, and spending — seeing it as gross “sausage making” or in sporting “who wins and who loses” score-keeping.
But for anyone who believes that health care in the wealthiest nation in the world ought to be a right and not a privilege, much is at stake in deliberations under way and, perhaps, soon to reach culmination.
It is difficult to predict exactly what will happen with President Biden’s agenda and his “Build Back Better” package, which contains major proposals that would improve Americans’ health.
As the Associated Press has reported, the plan started out to deal with:
“Dental work for seniors on Medicare. An end to sky’s-the-limit pricing on prescription drugs. New options for long-term care at home. Coverage for low-income people locked out of Medicaid by ideological battles. Those are just some of the changes to health care that Democrats want to achieve …. The … domestic agenda bill touches almost all aspects of American life, from taxes to climate change, but the health care components are a cornerstone for Democrats, amplified during the Covid-19 crisis. For the nearly 145 million Americans covered by government health programs, along with their families and communities, the investment in the nation’s services could make a difference in the quality of life for decades.”
Alas, the bill has gotten bogged down in political battling — with Republicans, as they long have, resisting any federal role in health care, and with Democrats tussling among themselves about the costs and priorities to address the nation’s significant needs. Frankly, it is an unhelpful major aspect of the mess that Congress now finds itself in — so riven by partisanship and procedural nonsense — that lawmakers now act only on gigantic legislative packages and only when confronted with the worst deadlines.
Sticker shock or problem labeling?
A partisan canard that savvy people should quickly dismiss, instead, has gained troubling sway over the discussions of the Biden plan — its purported $3.5 trillion price.
That seems like a whopping sum. But just consider: That is the projection of the bill’s cost over a decade. Recalculate the cost annually and it pops up at $350 billion, which is a goodly amount of money. Still, the measure would deal with many needs, including for universal pre-K education, child care, community college education funding, and more. But, by point of comparison, consider how little attention was paid to how fast politicians in the nation’s capital approved military and defense spending of $770 billion, or so, including a sizable increase in the Pentagon budget.
If that defense number were projected over a decade, it would reach around $8 trillion.
Does it make sense for the country to expend such an astronomic figure without question, while Washington, D.C., gridlocks over $3.5 trillion on an array of domestic programs, including to deal with climate change, and $1 trillion for desperately needed fixes of our roads, bridges, airports, railways, and broadband (the so-called U.S. “infrastructure”)?
Has it been forgotten so fast that this country spent more than $2 trillion on the losing war in Afghanistan — yes, much of it going in the pockets of corrupt politicians overseas but also sizable sums enriching U.S. defense contractors?
Democrats, of course, find themselves in the peculiar position of explaining in detail how they will pay for domestic spending, including by increasing corporate taxes (at some of their lowest levels in memory), taxes on the wealthy, and by savings achieved by allowing the federal government, finally, to negotiate with Big Pharma over exorbitant costs of prescription medications provided for those in federal programs like Medicare.
It also is baffling how the GOP — which provided more than $1 trillion in tax cuts to rich corporations and the wealthiest among us, as well as watching while the Trump Administration exploded the U.S. deficit by $7 trillion — depicts itself as the party of fiscal rectitude.
Republicans have flat out refused to discuss the Democratic plans, rejecting them out of hand, without saying what they dislike or would approve of (particularly if advanced by the GOP). The few Democrats resisting the plan also have not detailed their objections.
The costly, contentious issue of the Medicaid ‘gap’
An especially onerous part of the proposed health care changes affects Medicaid, the federal safety net program for the poor, working poor, the aged, and those with serious and chronic mental and physical illness. The Affordable Care Act, aka Obamacare, expanded Medicaid with federal support. But states, after court battles, got to choose whether to participate — and a dozen states, mostly in the South, have declined to do so.
This has put at heightened risk the health of 2 million people, most of them poor, uninsured, and members of populations of color. Without a safety net — available throughout much of the rest of the country — those who are most vulnerable also suffer miserable financial consequences as they go without medical care that leaves them sicker and more debilitated, meaning their costs are higher still when they do seek help. As the Brookings Institution has found:
“Nearly 80% of medical debt is held by households with zero or negative net worth. The blame for a lack of health care coverage should not be rigidly characterized as a class issue. Black households are more likely to hold medical debt. Twenty-seven percent of black households hold medical debt compared to 16.8% of non-black households. These findings corroborate a 2020 Urban Institute report that found medical debt was also higher and more concentrated in communities of color than in white communities … Black households are more likely to have medical debt at every age, but this debt disparity is particularly acute for black households past retirement age, when households have access to Medicare. Black households past retirement age still holding medical debt reflects how black seniors have been denied the ability to build wealth …
“Eliminating medical debt has a small ameliorating effect on the racial wealth gap, benefiting black people the most. Here, we repeat the methodology from our analysis of student debt. Cancelling medical debt shifts wealth up more for black households than non-black households, possibly revealing the impact of anti-black racism on health outcomes, but certainly revealing the impact of anti-black racism on access and coverage.”
It is fascinating to see that news media reports, for example, from the online information site Axios have characterized efforts to deal with the racial disparity of the Medicaid-coverage gap as a “moral” dilemma for Democrats — and not as the result of immoral conduct by Republicans unwilling to assist the most vulnerable in the country, especially if they happen to be black.
Let’ see how the Biden-Democratic plans, especially for health care, end up after all the lobbying and negotiations finish and the voting occurs on the bill. Will we regard it as a big advance in U.S. health care or a giant missed opportunity?
In my practice, I see not only the harms that patients suffer while seeking medical services but also their struggles to access and afford safe, effective, and excellent medical care. This has become an ordeal due to the soaring complexity, uncertainty, and costs of treatments and prescription medications, too many of which turn out to be dangerous drugs.
Americans spend more per person on their health care than their counterparts in advanced nations globally — and with worse outcomes. Our annual health care spending amounts to almost $4 trillion or ~18% of our gross domestic product. For the huge sums we throw at our health and the system that is supposed to care for it, we can do much better — and we have much work to do.
