We make many arguments for health care reform in general, and for universal access to health care reform in particular. We make arguments for social justice, for economic benefits, and other moral and practical arguments. We seem contented, for the most part, with the idea that the poorer you are, the less access to health care you should have. The lower your income, the more hoops you should have to jump through, the more humiliation you should accept in order to access the health care system.
This has actually been a longstanding debate, going back to the days of the New Deal, and whether Social Security should be crafted to help only the needy, by means testing of some kind or another, or be all inclusive as a social insurance program, everybody in, nobody out. In her book, "With Dignity," about the birth of Medicare and Medicaid, Sheri David notes that:
While the means test was an important method to determine who "deserved" help, the popular abhorrence of such a test was equally important. To have to prove poverty before a judge was so awful an experience that many risked starvation or lengthy sickness before seeking help.
President Johnson, in his remarks at the signing of Medicare into law, noted:
"This is an important hour for the Nation, for those of our citizens who have completed their tour of duty and have moved to the sidelines. These are the days that we are trying to celebrate for them. These people are our prideful responsibility and they are entitled, among other benefits, to the best medical protection available.
"Not one of these, our citizens, should ever be abandoned to the indignity of charity. Charity is indignity when you have to have it. But we don't want these people to have anything to do with charity and we don't want them to have any idea of hopeless despair."
[It is worth noting that Medicaid was also part of this bill, which does and did include means testing, and this was the favored approach of the AMA at the time.]
Does dignity matter? Should the poor be grateful for charity medical care? Should they be subject to the many indignities of being, as Uwe Reinhardt puts it, "health care beggars?" Reinhardt, in an interview for the PBS documentary "Sick Around the World," described an interview with the German Minister of Health:
And the other word she mentioned you don't hear here is "dignity." In fact, I finally interrupted her and said, "Do you notice that you have said 'dignity'" -- Würde is the German word -- "five times?" It's a [word] that's not in the American vocabulary. Here, the president will go on TV and says: "Oh, if you're uninsured, that doesn't mean you don't get health care. Just go to the emergency room of your hospital." But you go there as a health care beggar; you don't have insurance.
And the German minister of health would say, "But that's not a dignified experience." ... And that drives their health policy, because they have 200,000 uninsured in Germany -- that's 0.2 percent of the population -- and she thought it was a huge social problem, and she solved it. And we were asking her: "Why is that a problem? We wouldn't even notice that here. We've got 47 million, or 16 percent." And she says it had to do with dignity.
This is rarely even a part of our discussion these days. Even in our discussions of health care disparities, as we note that the poor in America fair badly in almost every aspect of health care (and education, for that matter), we do not note that they are beggars in our system and that, as Sheri David noted, this is not a position that a dignified human being deserves nor wants. Certainly, the tradition of social justice in all of our major religions, including all of the major Christian denominations, does not accept the treatment of the poor in demeaning ways. I picked the Evangelical Lutheran Church of America as an example of the consensus:
Human Dignity and Basic Needs: All human beings are entitled to the basic necessities of a dignified, humane existence and/or to the means of securing such. A right is what justice requires in response to particular human needs.
Human dignity should not be violated through provisions of a welfare policy that view human beings primarily in terms of their cost to the wider society, their job skill value, or the income they are able to generate.
Public policies should assure persons of their fundamental rights to adequate income, decent housing, health care, nutrition, and education.
In spite of the more than 45 years since the passage of Medicare and Medicaid, while we have addressed the needs of our seniors in having access to dignified health care, we have not done so for our growing poor and near-poor neighbors.