Is Healthcare Forever Doomed to Partisan Politics?

Look, plainly speaking: healthcare is my jam. It’s not a hobby for me, it’s my life’s work, and I’m not afraid to talk about it’s incredibly complex nuances.

I started my first year of nursing school nearly 20 years ago, and ever since then, I’ve been fascinated by all things related to providing my fellow humans with the care they need. First, I learned the fundamentals: how to start an IV, how to safely pass medication, how to do a thorough head to toe assessment. After I graduated and became an experienced nurse, I learned more advanced skills: how to run a code and save someone’s life, how to talk to a family of someone whose life no one could save, how to manage a 12 hour shift down to the minute, because there were never any extra minutes lying around (and no, I did not improve my poker game, despite some claims to the contrary of what nurses actually do.) After mastering those skills, my fascination became “how do we make nurses, and nursing as a profession, better, safer, more efficient?” I worked as a Nurse Educator, teaching new nurses after they were hired, working with hospital leadership on initiatives to improve overall care delivery, and finding out the best strategies to be always improving on our quality of care. Most recently, I’ve been working in the realm of population health, and trying to answer the biggest question of all these days: how can we get the whole country better healthcare?

The answer is not simple, it’s really not.

I recently attended a healthcare event with my U.S. Senator, Debbie Stabenow. Sen. Stabenow has been a leader on improving healthcare since before I started college, and I am very grateful for her leadership. She has championed healthcare topics like lowering prescription drug costs, funding rural health centers, and working across the aisle to expand coverage for Alzheimer’s patients. She has lots of great plans to help to improve the public’s health, and is also willing to entertain and support new ideas as well. During this event, I had the opportunity to discuss with her one specific request: to please help further a bill brought up in the House — Seniors’ Chronic Care Management Improvement Act (H.R. 3436), introduced by Reps. Suzan DelBene (D-WA) and Peter Welch (D-VT), that would allow a Medicare program called “Chronic Care Management (CCM)” to be considered preventative care, and therefore not subject to a co-pay (#ThanksObama).

You see, in our current traditional Medicare system, the individual patient is still subject to co-pays for treatment services, 20% of those services to be precise. Now CCM is a fantastic program where seniors who have multiple medical problems, or who have frequent, avoidable ER or hospital visits, are given a case manager to work with, an individualized care plan, and 24/7 access to their primary care doctor so they can get all the care they need upfront, thus avoiding the ER. This program is a win/win/win: it provides better healthcare to patients who are chronically ill, it decreases overall Medicare spending, and it reduces the burden on the primary care physicians who are caring for larger and larger numbers of patients as Americans age. But since this is not currently considered a “preventative care service”, Medicare beneficiaries are still subject to a monthly co-pay for this program. The cost is generally only about $8/month, but for many seniors, that is just not something they can afford (Fixed income + hundreds in prescription drugs a month for those who fall into the Medicare Part D “donut hole”=poverty.) And since doctors and patients are subject to very strict Medicare rules about billing and co-pays, it can’t just be waived either, no matter how much good it would do. So we need to lobby our lawmakers to make a whole new law, just to enable this program to be more accessible to the seniors who need it the most.

Senator Stabenow agreed to support the bill after our brief discussion, but also noted that this bill, and any other bills about healthcare, are only going to get enacted into law if we ever have a majority who actually gives a damn about healthcare again. After her remarks, she held a question and answer session and knowledgeably answered many questions on lots of topics, including the healthcare epidemic that is gun violence. She also advised that the best thing that a healthcare advocate could do would be to vote. (More here)

This is generally the answer we have for a lot of the things we want to see change on —” vote, so we can have a pro-insert issue- majority”. We know that all the advocacy in the world only goes so far, and that unless we have seats at the table, we will forever be on the menu. While these sentiments often give me renewed vigor to Get Out The Vote (GOTV), this time, it gave me an even more sinking feeling in my stomach (which I didn’t think could sink much lower these days.)

Hearing this same answer left me with one more nagging question: will healthcare be forever a political football? Maybe healthcare reform will move us to vote en masse in 2020, but what about 2022, 2024, 2050? Will we forever be one vote away from having real, comprehensive healthcare benefits taken away? Understanding the pendulum swing of politics, and our ever rotating power structure, I was surprised I had never asked myself this question before.

I have been trying to refocus the healthcare debate we are currently having from one of “pick a side” to one of “no matter what system we have — WHO gets to decide WHAT is covered?” After this startling, and frankly exhausting realization, I want to now add this— “and HOW will we protect it from partisan politics?” Or can we?

Medicare, which is currently seen as the most popular form of insurance in the US (despite the warnings from opponents decades ago that it would be socialism and the end of Western civilization), is still a far from perfect system, with giant holes in coverage, and what is and isn’t covered is still subject to the whims of partisan politics. Medicare rules are decided by CMS (Centers for Medicare & Medicaid Services) which is headed by a cabinet level presidential appointee, making it an inevitable partisan chess piece. Especially now, holes in the budget (made by large tax give aways to the rich) are usually suggested to be filled with making cuts to Medicare and/or Social Security, which would mean cutting down on WHAT is covered, and by how much.

State Medicaid rules are subject to state legislatures, which are vehemently partisan, and Medicaid benefits are often used as the punching bag of choice for those looking to show their toughness on ‘those lazy…babies, disabled people and grandmas in nursing homes’, because that’s where majority of Medicaid dollars go, but I digress. The VA System (TRICare), which is the US’ only real form of “single payer” (since Medicare, Medicaid, and private insurance all use more than one payer source, which includes yourself paying anything out of pocket for care) is widely subject to political office holders. Even private insurance rules are under the jurisdiction of politicians. One need only look at the ACA, and the subsequent and current legal battle to overturn it. The battle for the ACA patient protections were hard fought, at great political cost, and now are potentially lost, with what to show for it, and what protections for our healthcare will be left?

Long story short: all our forms of healthcare coverage seem like a never-ending political football. As we continue with our discussions of healthcare reforms, I want to add this question to the pile, as I feel it is one that we would be remiss to not include. And that is:

Once we win a truly universal healthcare coverage solution in the US, how will we protect it from being gutted, and becoming coverage in name only, akin to our now legal again “junk plans”?

Hear me out:

I fear that many people wrongly believe that once we have a Democratically controlled majority in the House, Senate and retake the Presidency, and we achieve some kind of universal healthcare (be it Medicare for All, Medicare for America, ACA 2.0, etc,) that we will have won the war, and all will be well. If we learned anything from the backlash of the ACA in 2010, I hope it was that every bold new policy has a fierce and sometimes politically costly consequence. What I fear is that we will pass healthcare reform, and have a government centered healthcare system, only to have that very government (when NOT held by a majority of healthcare advocates) later turn around and gut what we all need and are fighting so hard for: comprehensive coverage.

I want to avoid this very fiasco, of assuming we’ve won a victory, when in fact, we’ve given away control of the very thing we’ve fought so hard for, to a future, hostile majority.

So my new question to anyone discussing healthcare: in your ideal system of healthcare coverage — WHO gets to decide WHAT is a covered service, and HOW are we going to keep those two things from being an endless political football? What safeguards can we also put in place to protect our hard fought healthcare so we are not at the endless mercy of political majorities?

Failure to have a good answer for these questions, and a solid plan to enact it, will doom any future reforms to our endless cycle of placing patients in the middle of partisan politics. Failure to address this very real concern will continue to keep us sicker, poorer and living shorter lives than past generations on Americans. It’s not enough to pat ourselves on the back and say “we did it” in the next administration, if all this hard work and advocacy never actually makes anyone healthier in the long run.

If we have the political will to make big bold changes now, we need to also have eyes that see 10, 25, 100 years into the future, and put protections in place to ensure that comprehensive healthcare benefits are the right of all future generations of Americans. Otherwise we will have just put a band-aid on this bleed, allowing it to be ripped off when we are inevitably back in the minority again.