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Vol. LX, No. 23
November 14, 2008

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To Have and Have Not
Why America Resists Universal Health Insurance

  GWU’s Dr. Stanley Reiser tackles the issue of universal health insurance coverage.  
  GWU’s Dr. Stanley Reiser tackles the issue of universal health insurance coverage.  

A stubborn problem at the heart of American life is the plight of the medically uninsured and the underinsured, around 72 million people.

Recently, NLM invited George Washington University Medical School’s Dr. Stanley Reiser to tackle the question from a historical perspective.

“Why the profound reluctance to draw on federal resources to pay for universal health insurance?” he asked a full house in Lister Hill Auditorium.

Our history as Americans, said Reiser, stems from rebellion against monarchy. We wanted to be left alone, to hold government at arm’s length and to lead an independent life. One side of a coin displaying these ideals would be “the ebullient face of liberty as a fundamental right; on the other side would be the stern face of responsibility.”

With responsibility to care for life’s basic needs an overriding American value, only narrow segments of the population got medical help. The idea is that only special groups were candidates for such government assistance. This “exceptionalist doctrine,” Reiser said, is “much more fundamental than previously believed.”

Those exceptions have included, among others: veterans, the poor, the aged and infirm, mothers and children and those afflicted with certain diseases, with kidney disease a case in point. When dialysis was developed as a life-saving measure, U.S. legislators were successfully lobbied in order to support it.

The first example of exceptionalism dates from 1798, when the Merchant Marine Hospital Service was established under U.S. law and sailors were offered care in a comprehensive system of hospitals. This agency later became the U.S. Public Health Service in 1912.

GWU’s Reiser thinks a mixed system of health insurance has the best chance of appealing to the nation.

GWU’s Reiser thinks a mixed system of health insurance has the best chance of appealing to the nation.

As valuable strategic assets for national well-being and commercial strength, sailors were considered a special population for whom government should help provide care.

“Yet [hospitals] also made [sailors] pay” for part of the care, Reiser explained. “This is emblematic of the two sides of the coin, of largesse and responsibility.”

So exceptionality arose, Reiser said, “when a case of compelling social or personal need created public subsidies for particular groups.”

But look what happens when you bundle those special groups.

If we integrate all the exceptional categories—from those served by the Veterans Administration, to programs like Medicare/Medicaid; and if one adds employee coverage from federal, state and local governments—then almost half the people in the U.S. get some form of government assistance.

“Such selective coverage,” Reiser said, “logically leads to the question [coming from] those without subsidies and in medical need: ‘Why them and not us?’

“This is one of the main issues we have to confront,” he continued. “A moral dilemma: Why are only certain groups worthy? Isn’t it time to do something for the rest?”

We now need a system that fits not only our purse, he said, but also our values: a mixed system that would include employer-based coverage, federal assistance (subsidies, tax credits), public insurers and individual responsibility.

A primary care physician in the audience objected. She spoke up for more drastic, sweeping change.

Reiser still held that a mixed system might have the best chance to accommodate the “varying levels of power” spread across government and private entities.

“Part of the problem in the literature on this subject,” he concluded, “is that it’s focused on efficiency. But that’s not enough. Any [health insurance] system must fit our value system.” NIHRecord Icon

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