I have spent the past week on what has to be one of the wonkiest binges in my recent memory. Buoyed by a cycle of uncertainty, elation (briefly confounded by the CNN twitter stream), culminating in relief, I think I have devoured every piece of health law arcana and Supreme Court intrigue I have come across since the decision to uphold the ACA mostly intact came down last week. But a return home for the fourth of July holiday weekend quickly reminds me how easy it can be to start living in the bubble. In this bubble of mine- everyone takes an active position on health care reform, examines the numbers, weighs the politics. I even saw an article in the local paper about Chief Justice Roberts attending a legal conference in the county last Friday, the day after what will likely be one of the most significant decisions during his tenure came down. When asked about his summer plans, after what seemed like a trying and exhausting court term, he answered he was teaching a course for 2 weeks in Malta, "Malta, as you know, is an impregnable island fortress. It seemed like a good idea." But then reading and hearing a response of mostly “Who?” and “What now?” quickly bursts that bubble I’ve been living in.
I have trained and spent the formative years of my time in medicine in New York City, which if nothing else cannot be accused of being passive in its approach to public health. The state provides relatively generously in its Medicaid, standing to gain less than many other parts of the country from parts of the ACA. But I grew up and went to college in western Pennsylvania- which is nothing if not a bundle of contradictions when it comes to politics. It’s a state that typically leans Democratic in presidential elections, but has both a State House and Legislature currently dominated by Republicans. It is the home of former Senator Arlen Specter, a pivotal vote in the original passage of the ACA, but Governor Corbett was among the governors bringing suit against the ACA. And now that the feeling of relief from last week is ebbing, the significant role that states will play in implementing the details of the ACA is coalescing around setting up health exchanges and the now optional Medicaid expansion. It is in this convoluted landscape that Governor Corbett issued the following in response to the Supreme Court decision:
“It is a tax on our citizens that they cannot afford. It is a tax that hits our small businesses the hardest and will kill job growth. This law will raise healthcare costs for our families, our employers and our state. This is a burden to all of us who work every day to recover from the recession.”
While one could go point by point as to how this statement isn’t accurate, I’ll leave until another time. More importantly, when it comes to what that means for the residents who stand to benefit from the state derived portions of the ACA, the governor has chosen not to elucidate his position on either the exchanges or the expansion, instead staying in a holding pattern. The state continues to “study” the prospect of exchanges, and for the 800,000 people who could get access to critical health coverage through the expansion, the answer has been silence. And this silence resonates; according to a Kaiser poll only 6/10 people know the ACA was upheld last week. By not drawing attention to the issue and given these major provisions don’t come online until 2014, unless we continue to act as strong voices for the benefits of the ACA, these concerns may fade in the background. And while that same poll says 56% of respondents want opponents of the ACA to move on to other national problems, we have to continuing being advocates for robust implementation, lest all the progress being made be quietly neglected at the state level.
Pennsylvania is a rather typical state in many respects, while actually besting the national figures in both rates of uninsured (11%) and unemployment (7.4% as of May 2012). Statewide, this may make health care coverage seem less pressing, but for somewhere like the county where I grew up, the need is palpable. This is a place where, in addition to the Chief Justice, the local paper’s recent front page headlines have included: “Man's Green Thumb Produces Elbow-High Corn Stalks", "Robber takes more than 4,000 oxycodone pills from Walgreens Drive-through" & "Limits on Yard Sales." 19% of persons live below the FPL(federal poverty line- $23,000 for a family of 4). The median income is $34,000 (compared to $50,000 statewide). 26% of persons are eligible for medical assistance, and this in a state where while pregnant women & infants are eligible up to 185% of the FPL, but children 6-19 are only covered up to 100% of FPL, and working parents up to 46% of FPL. To be clear: that is about $10,500.
If the state would accept the Medicaid expansion up to 133% (think $30,500), 800,000 people could get desperately needed coverage, with the federal government contributing 94% of that bill for the first 5 years. When I think of the relief this could provide to my hometown, where by the numbers a little less than half of the population might be eligible, I am overwhelmed. And yet the tone of the conversation here is still mostly negative, if one knows about health care reform at all. And while it is hard for anyone to find fault with a lot of the specifics (no pre existing conditions, coverage for young adults, no lifetime caps), there is still a general foreboding about the law as an encroachment of the government on some nebulous idea of freedom. I have heard that we are now Communists. That because of things like this China is going to come buy the coal mines. And most confounding of all, “I just don’t like it. It doesn’t feel right.” But remind someone these were the same thoughts that happened with each step of health care reform, from the VA to Medicare, and I have seen a different expression cross their face. What was once controversial, is now just the way things are. I am just reminded of all the individual conversations that still need to happen. All the benefits we need to continue to elucidate, all the lobbying we need to keep doing on the political front. After the victory at the Supreme Court last week- the real work is just beginning. And the medical profession has a critical role to play. And with some apt advice from 20th century Britain- Keep Calm and Carry On.