Forgive the World War II reference, but as I write this, I am reminded of the estimate of 45,000 deaths attributable to lack of access to health care, not even counting the countless maimings, wounding, and psychological hurt inflicted on the uninsured and under-insured in America, it seems appropriate. It is not an existential threat to our democracy, but this is, make no mistake, a battle for the soul of our country. As Michael Moore put it in “Sicko,” is America about “we” or “me?”
As physicians, we are obliged to be about “we.” In the Charter on Medical Professionalism, we are enjoined to seek social justice in the delivery of medical care, to be good stewards of our health care resources. Specifically, physicians “should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”
We are also our patients fiercest advocates, and that includes those who can afford to see us and those who cannot. We all have our favorite collection of horror stories of the American healthcare system leaving individuals to fend for themselves with no hope of accessing the system until it is too late. Part of my anecdote collection is here, and I always trot it out when I am told a third hand anecdote about how bad health care is in “other countries.” For most Americans, health care is pretty good, but for the uninsured or under-insured, America is a third world country: access to care is completely dependent upon ability to pay.
Remember that, only in America of all advanced nations, have we answered “No!” (or perhaps “Hell, no!” from some) to the question of whether, as Uwe Reinhardt has put it, “As a matter of national policy, and to the extent that a nation's health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?” Medical ethicist Arthur Caplan argues that lack of access to health care is a fundamental road block to equality of opportunity in America, that placing the additional hurdle of untreated illness on a large segment of society is inherently unjust.
It has been pointed out that Americans are singular in the world in our Christian religiosity, but this religiosity is characterized by public policy consistent with ruthless Social Darwinism in many respects, while Europeans are pointedly irreligious, yet have structured their societies to function along a very progressive commitment to social safety nets, social justice and equality of opportunity, as well as a very Teddy-Rooseveltian distrust of great accumulated wealth.
I, as do many, take pride in my religion's unwavering commitment to Social Justice, Glenn Beck's disapproval notwithstanding. It is what keeps me a Catholic, and I am sure it is what keeps many in other traditional churches. It is, in fact, fundamental to every religion, Christian, Jewish, Muslim, Hindu, Buddhist and more, and most non-religious philosophical paradigms as well. I am well aware, however, that the most influential book outside of the Bible in America, “Atlas Shrugged,” and its author, vehemently reject all such sentiment as counter-productive nonsense. And this book is widely commended by conservatives who consider themselves deeply religious Christians.
So, this basic ethical commitment to fairness, tending to the sick, the poor, the treating of others as we would wish treated, is pervasive among every population in the world, except for those who follow the Ayn Rand school. I cannot fathom this, as I think the cognitive dissonance of holding both Christianity and Rand dear would be incapacitating, but there it is, and it is rampant in our political and clerical classes.
The argument is frequently made to me that their Christianity only allows for individual charity, not state sponsored programs. That is nice in theory, but as even Mike Huckabee acknowledged,
“If there are a certain number of kids from single-parent homes who aren’t going to school and don’t have health care, you can say that’s not government’s job,” Huckabee told me. “Well, sweet and fine! But you know what? If the kid’s sitting outside the door of the hospital choking with asthma, do I sit there and say, ‘Oh, I’m sorry, I don’t think, philosophically, government should get involved’? I’d much rather the kid get help than I sit around and say I’m so pure in my ideology.”
And, frankly, the milk of human kindness has not flowed freely enough anywhere in the world to provide health care to a population, and I don't expect it to do so now. I don't think giving it another century to work itself out is a reasonable strategy.
We fight because of the fundamental unfairness of the system to so many. One in six Americans is uninsured, another one in six under-insured; the deaths, injuries, bankruptcies, anguish and degradation of basic human dignity are why we fight. The America I grew up in was working on being better than this. The Great Society programs of LBJ took us a long way forward, and we have been painfully stuck in place until the passage of the Patient Protection and Affordable Health Care Act in 2010.
PPACA represents our rejection of treating so many of our brothers and sisters and our patients as lesser human beings, less deserving, less worthy of our help. Let's keep fighting for “We the People,” and fight those only concerned about “me.” Ayn Rand and Glen Beck notwithstanding.