BUFFALO, N.Y. -- Debra Street, Ph.D., associate professor of
sociology at the University at Buffalo, says the history of health
care reform in the U.S. is "one of lost battles" for principled
approaches to creating a health care system that delivers good
health care to all.
Street is a health care policy expert whose research analyzes
the impact of public programs and tax policies on health and income
security. She studies the unintended consequences of public
policies on long-term care outcomes, and the politics and policy
histories of public expenditure.
In the following Q&A, Street cites the "deliberate
deception" involved in the current health care reform debate, and
she tells us who is lying and why -- and who will end up
Do you think the health care reform debate is taking place in
Street: "No. No side has the courage to tell the absolute
truth because it isn't expedient to say out loud what needs to be
said. Politicians lack the courage to tell the truth in the face of
their re-election plans.
"Pro-reformers need to say, 'nothing but a huge amount of
government intervention will change things enough to get us to the
goal of universal coverage.'
"Anti-reformers need to say, 'Lack of health insurance for
millions of Americans is less important to us than protecting the
integrity of American self-reliance and markets and the profits of
insurance shareholders.' Maybe if all sides of the issue told the
truth, we could have a real, honest national conversation about
what is at stake in health care reform."
In your opinion, who is blocking "real" health care
Street: "If we want to understand what is blocking
reform, just follow the money. Those who have the money are
controlling -- or more accurately obfuscating -- the debate.
"The characters who want to block reform may change over time,
but one enduring feature of this group is that it is not concerned
with what is best for the health care of the nation. They are
consistently and exclusively concerned with what benefits them and
their shareholders financially. This is about money remaining in
the hands of certain groups.
"Historically, universal access to health care was blocked by
physicians through the American Medical Association and hospitals.
Today, there is a new alliance of political convenience that
comprises health insurance companies, the pharmaceutical industry
and ancillary providers -- all of whom profit from current
arrangements. This is the group that is doing its utmost to stop
"There are about 45 million uninsured Americans, and
out-of-control health care spending continues to increase, but this
is situation is that works best for this alliance. It profits them
most, it keeps power in their hands and make no mistake -- they do
not want it to change.
"The longer the public can be misled and mystified about the
nuts and bolts of potential reform proposals, the longer the
'winners' under current arrangements continue to 'win' and the
others continue to lose."
What do we need to know about this public battle that we are
not hearing through most news coverage?
Street: "First, we need to know that our health care
system is not very systematic and that health care reform is very
complex and difficult to fully understand, even for the
"Second, we need to know that opponents of health care reform
bank on our confusion. They know that it is easy to deceive and
mislead the public about what the proposals entail, what they will
cost, who will benefit and who will lose under different scenarios.
And they use that knowledge to misrepresent the situation in ways
that will benefit them.
"Third, we must recognize that no matter what health care reform
is eventually enacted, whether small and incremental (the most
likely kind of reform) or broader, there will be winners and
losers. There are few policy changes that are win-win, and health
care reform definitely isn't one of them."
You say that all parties in this debate deliberately
obfuscate and mislead the public?
Street: "All sides play some of that game. Pro-reformers
pitch their programs in ways that minimize cost estimates and
understate the role government would have to play in meaningful
reform. They shy away from saying out loud that it is the pretense
that there is a 'real market' in health care in the United States
that prevents us from accomplishing what every other democratic
country (and some not-so-democratic ones) have achieved: routine
access to high-quality health care for all.
"The anti-reform side throws out scare phrases, like 'socialized
medicine' and 'euthanasia' and 'Medicare cuts' and 'government
health care' and 'higher taxes' to try to intimidate the uninformed
into supporting the status quo -- even though the status quo, which
is a lack of health security, is against their own interests. But
this is a notoriously difficult debate in which truth can
"Neither side has the courage to tell the absolute truth because
it isn't expedient to say out loud what needs to be said. Our
politicians lack the courage to tell the truth in the face of their
plans for re-election."
Where should we be focusing our attention?
Street: "In terms of reform, we should probably be
focusing our attention on pragmatic policies that build on and
expand programs already in place.
"These include employment-based health insurance programs,
including potential for buy-in to what federal government employees
have available to them; Medicaid, SCHIPs (State Children's Health
Insurance Program), Medicare. We can raise the income levels on
Medicaid eligibility, for instance, sweep more kids into SCHIPs,
lower the age of eligibility for Medicare to include older workers
who have been downsized in this economy and who cannot get
commercial health insurance.
How can individuals influence the outcome? Should we take
individual action or support groups that promote our vested
Street: "I wish I knew how we could influence the
outcome. I really don't know. It is difficult to organize many
people with little in common but a hope that someday Americans will
have an irrevocable right to decent, dignified health care -- not
something that comes and goes with employment, or poverty status or
age, but something to which we are all entitled that contributes to
the common good.
"The pockets of reformers simply will never be as deep as the
anti-reformers. Health is a pretty recession-proof industry and
health profits fuel a lot of noise in the system, from
sophisticated ad campaigns to phony 'grassroots' anti-reform
organizations that are nothing more than fronts for the
organizations and industries that do well under current
circumstances. It is frustrating.
"Sadly, there is not much the public can do to influence the
outcome, I'm afraid. But it doesn't mean people shouldn't try."
What kind of health care reform are we likely to get after
the dust settles?
Street: "We'll get what I call 'frankenreform' (no
intention to besmirch our new senator, here). It will be a little
bit of this, a little bit of that, a little bit of something else,
stitched together, with a nut and bolt or two, then electrified at
a big news conference. It will only change health care delivery at
the edges. Maybe that is okay. The history of health reform in the
U.S. has been one of incremental change, so to expect a revolution
of the U.S. health care system isn't realistic, no matter how much
we think it is needed.
"But even little bitty reforms will finally sweep some people
into the health care system and make a huge difference in their
lives. So I try to think of this as accepting that some good may
come from these efforts, although health reforms will be hard
fought, and few won."
Should we be afraid of a miserable outcome from what looks
and sounds like a terrible battle among corporate interests for the
Street: "My hunch right now is that the outcome of this
health care reform won't be entirely miserable, there will be
enough small changes that reformers can claim some advances and the
anti-reformers can afford to concede small changes as long as
current arrangements remain essentially intact.
"I doubt the reforms will be any more revolutionary than the
outcomes of the Clinton-era health care reform efforts. There will
be some new quality regulations, a spasm towards some kind of very
limited cost controls (because these are what anti-reformers fear
most), there will be some adjustments in program eligibility that
will include a few more people under public programs, but the
fundamental problem of health insurance insecurity when a person
loses a job, or somehow doesn't quite reach the bar for eligibility
in a public program, will remain.
"Those without health insurance who get sick or injured won't be
covered under whatever reform package finally emerges."
Who stand to be the biggest winners and losers?
Street: "If I were a betting woman, I'd bet that this
will be one of the signature political losses of an Obama
administration. I think that the lack of clear and dependable
information about the ramifications for health care reform is a big
stumbling block, but the biggest stumbling block by far is the deep
pockets of the industries that have those deep pockets because of
the way health care is currently arranged. Still, the political
effort to expand health care coverage to more Americans is a
political battle worth pursuing. I really hope I'm wrong about who
the winners and losers will be."
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