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If not now, when?

By Dr Harold Pollack

My comments at a plenary panel for the national leadership meeting of Doctors for America, a health care advocacy group. These have been edited for a different context.

Thank you for having me today. It’s an honor and a pleasure to be here among friends. We have a short time and a long list of issues. I hope we will get into the mechanics of accountable care organizations, mandates, exchanges, and the rest. But I want to open with something different. It will seem like a tangent. It actually speaks to this meeting’s larger purpose.

On April 6, the distinguished Chinese physicist and dissident Fang Lizhi passed away. According to the Economist’s obituary, Fang got in trouble writing a 1972 paper “A solution of the cosmological equations in scalar-tensor theory, with mass and blackbody radiation.” Unfortunately for Fang, Maoist propagandists found Einstein’s field equations politically unacceptable. At some 50,000 foot level, the big bang theory was deemed contrary to proper Marxist-Engels thought regarding the transition to state socialism. At a more practical level, apparatchiks rightly feared the democratic potential and intellectual authority of scientific inquiry. Their claims of unique insight couldn’t stand that scrutiny.

During the Cultural Revolution, Fang was apparently exiled to a coal mine carrying only one book: Landau and Lifschitz ‘s Classical Field Theory. I actually know that book. I broke my pencil on it a quarter-century ago in engineering school. Landau and Lifschitz were two great Jewish Soviet physicists. They were both protected and persecuted by one criminal regime locked in a death struggle with an even worse one.

I learned something about Landau and Lifschitz from a wonderful, now-deceased theoretical physicist Abraham Pais. He had spent the war years hiding from Hitler in an Amsterdam attic. Rather than write a poignant diary as someone else might do, Pais wrote a distinguished dissertation on particle physics. That’s humbling for many of us who have head-tripped over our own dissertations. Forty-five years later, Pais would frequent the Princeton math library where I worked nights checking out books. With great difficulty, I read his award winning scientific histories of modern physics.

Last week was Holocaust Remembrance Day. How do we honor survivors such as Pais? How do we honor people like Fang, as well? Continuing, in our own lives, their commitment to science and to human rights is one excellent way to do so. In a keynote address to DFA members, Harvard lecturer Marshall Ganz noted his own connection to the Holocaust through his father’s work with survivors in DP camps. This experience led Ganz to trek from Harvard down south for civil rights work, and later to assist the United Farm Workers.

Ganz wasn’t alone. During Mississippi’s Freedom Summer, a disproportionate number of civil rights activists spoke of the Holocaust in explaining why they were willing to face real dangers in the Deep South.  Andrew Goodman and Mickey Schwerner gave their lives in this struggle.

Not a few physicians such as Jack Geiger made the same trek. When Mississippi delta children presented with malnutrition, he wrote them prescriptions for food. Called on the carpet, an unrepentant Geiger responded: “The last time I checked my textbooks the specific therapy for malnutrition was, in fact, food.”

I’m a policy wonk. But I’ve worked the past four years with DFA for a simple reason, because I believe access to affordable health care is a human right. On the campaign trail in 2008, I met people facing medical bankruptcy because they were medically uninsured, because they had maxed out their coverage, because they just couldn’t pay high copayments and deductibles when they got really sick. I see so many people around the Chicago southland facing similar difficulties.

The Affordable Care Act, complex and imperfect as it is, has already made a difference. It ensures that our health care system treats people with greater decency. It will make an even bigger difference once fully implemented. Opponents of ACA dance around what “repeal and replace” really means, which is to deprive thirty million people of affordable and effective health coverage.

Opponents of ACA are acting with a sense of political urgency. They know, as former Bush official James Capretta told me, that after 2014, “once the money starts flowing,” neither state governments nor individual recipients will allow these benefits to be taken away.

Health reform raises technical issues. It raises political and ideological issues. But at bottom, it raises an inescapable moral issue. We spend $2.8 trillion on health care. We still don’t treat people decently.

I see this every day, as a relatively affluent person helping to care for someone with an intellectual disability. Some of you have read my columns about my brother-in-law’s care. He has his basic needs met. Many of his peers close to home or around the country have poor and worsening access to dental care—an optional service that may be dropped in Illinois Medicaid. These men and women face punishing copayments. Those who are not on Medicaid were effectively barred—in the absence of the ACA—from gaining health insurance coverage.

Then there are the direct care workers who care for them. These are the people we trust when we’re not there to see: to calm our loved-one when he is anxious, to occasionally change some soiled linins, to keep him safe and healthy. Around the country, their average wage is $11.24/hour.  Many go uninsured. Representative Paul Ryan recently told reporters:

“We don't want to turn the safety net into a hammock that lulls able-bodied people to lives of dependency and complacency, that drains them of their will and their incentive to make the most of their lives.”

That’s not the way to think about, or talk about, working poor people who are the chief beneficiaries of Medicaid, CHIP, and other benefits, too. We have to stand up to that. We must also understand that we’re all in this together. My household needs help to care for a disabled family member. Someone else needs health insurance or maybe help finding a job. A high school senior needs a Pell grant to attend college. Rather than each of us fighting for our own special interest or need, we need a larger vision in which each of us chips in to help others when they—when we—need help.

I recently read Theda Skocpol and Venessa Williamson’s wonderful book on the Tea Party. Their book was a rare combination of sympathetic understanding for admirably passionate, politically engaged fellow Americans, with a properly scathing critique of what those passionate, engaged Tea Partiers are actually trying to accomplish.  I am so disappointed to see many people richly benefit from Medicare and Social Security—and then turning around to oppose efforts to deploy public resources to meet other social needs. We should be equally passionate and engaged on behalf of something different.

Professor Ganz stole my concluding lines by citing the most quoted line in all of Judaism. It is not from the Bible. It’s from Rabbi Hillel: "If I am not for myself, who will be for me? But if I am only for myself, who am I? If not now, when?" That’s not bad as a parable about health reform, in everything from the responsibility implied by the individual mandate to the fundamental argument to protect each other through social insurance.

Will we continue to allow cancer patients to lose their homes? Will we allow poor people to die sooner than they otherwise would because they lack insurance coverage? Will we protect each other from burdens that would crush any one of us, were we forced to bear these burdens alone? Will we delay another generation before moving towards universal coverage? Speaking across two millennia, Rabbi Hillel might be asking these same questions.


Harold Pollack is Helen Ross Professor of Social Service Administration, and Faculty Chair of the Center for Health Administration Studies at the University of Chicago. He has published widely at the interface between poverty policy and public health.  His research appears in such journals as Addiction, Journal of the American Medical Association, American Journal of Public Health, Health Services Research, Pediatrics, and Social Service Review. His essay, "Lessons from an Emergency Room Nightmare," was selected for The Best American Medical Writing, 2009.

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