During early 2017, U.S. political headlines were dominated by political maneuvering and grassroots organizing prompted by Congressional attempts to repeal the Affordable Care Act. Now health care reform is in the news again with the announcement of Senator Bernie Sanders’ “Medicare For All” bill. Gunnar Almgren is a Professor at the UW School of Social Work and a faculty associate of the Center for Human Rights. His timely book Health Care as a Right of Citizenship: The Continuing Evolution of Reform was published in 2017 by Columbia University Press. We spoke with Professor Almgren about the historical and philosophical impetus—and barriers—for fundamental health care reform.
How did you come to write a book on this topic?
I’ve taught health care policy for 25 years, after a background in social work practice and health care in safety net hospital systems. I’m interested in this idea of not only universal access to health care, but what are the moral foundations of a social right to health care, and how do we reform our health care system to meet those requirements. My research work has focused primarily on health care disparities and the role of class and race in not only different health outcomes but also disparities in health care. So all of that mix went into taking this moment in history and saying, what is the significance of the Affordable Care Act, where do we seem to be going, and from the standpoint of political democracy where do we need to go?
You argue that despite the results of the 2016 election, the Affordable Care Act (ACA) is here to stay. So far you have been proven right. Why has the ACA endured?
I had actually finished the book prior to November 2016, and after the election my editor phoned in desperation and said, “What are we going to do? We have this book coming out saying that the ACA is here to stay!” So I said that while I wouldn’t revise the book, I would revise the preface. What the preface says is that there are two alternative historical narratives of the ACA. One is that it’s like Johnson’s War on Poverty; that it is a bridge too far in a progressive social agenda and it will be deemed a policy failure.
The other narrative is that it is a historical step, and that—control of Congress aside, political rhetoric about repeal and replace aside—it expanded access to health care, and articulated a social right to health care, in ways that would make it very difficult for Congress to retreat from. The argument has been made that the resistance against the repeal of the ACA was due to the fact that once you enfranchise people, once you provide them a benefit, it is difficult to take it away. There is some validity to that argument but I find it simplistic, and frankly a little arrogant.
There are some other realities here. The context of the passage of the ACA was that the financing system of health care was in a state of collapse. The employment-based insurance approach had been deteriorating for decades, covering fewer and fewer of the nation’s workers and their dependents. As of 2010 even middle-class families could not be assured of adequate health insurance. We had 49.6 million uninsured nationwide at that point.
Also, the ACA gave a face to the uninsured. The uninsured were largely, for many Americans who had insurance, a kind of unseen. All of a sudden, people had access to health insurance and care, and the changes that made in their prospects and in their lives was visible. So it’s not just a matter of taking something away, it is the visible face of the uninsured, and the creation for them of an alternative future that the ACA brought about, which has made it, not immune to repeal, but a very heavy lift.
Your book embraces the idea of health care a human right, and you argue that a social right to health care is actually essential to democratic society.
Every fall when I teach a health policy course I begin by asking, “Is there a right to health care?” And almost all of my students say that there is. And I say, “Why?” It’s interesting to see them struggle with that, and you get these different arguments that come up. What I don’t hear is the connection between the requisites of political democracy and the substantive rights that are essential to that. In my view, the two titans of social rights in political democracy are John Rawls and T. H. Marshall. I saw a synthesis between Rawls and Marshall, that there are two complementary theories about the argument of certain social rights being essential to political democracy. One from the argument of moral philosophy, John Rawls; and the other was more of a historical sociology argument: how have social rights evolved and why did they evolve? That’s the T. H. Marshall piece, that certain social rights became necessary to the long-term viability of political democracy.
So what I endeavored to do in the book was to ask, what are the arguments for a relationship between the viability of political democracy and specifically a right to health care? And if there is such a right, what are its essential substantive requirements? And to me the way you get to that is not simply listing, well, everybody should be able to have a primary care doc, and everybody should be able to have hospital care, and maybe long-term care, arbitrarily listing all the things that someone might need over the course of their life. You have to define the principles that link rights to substantive requirements first, and then based on those principles create the financing and delivery structures capable of fulfilling them.
There’s a moment in the book where you allude to future eras of reform, and the possibility that not enough people’s health care is threatened at this moment to enable the next leap forward. Do things really have to get worse before they get better? And more optimistically, what potential do you see for that future evolution?
In very simplistic terms, there are two impetuses to the politics of fundamental reform. One is a vision that gets enough proponents, that gets enough political momentum to where at least in incremental terms we create policies in pursuit of that vision. That mostly doesn’t happen. What the lessons from history tell us is that it requires a fundamental collapse of yesterday’s solutions to bring about fundamental change. It would almost be ahistorical to say that I see a path to us getting to a consensus on fundamental health system reform in absence of a national health care crisis.
That said, there is some evidence of a growing national consensus toward a more rational system of health care financing. We see evolvement in the medical profession’s position. If we look at the American Medical Association (AMA) and its historical power, there was a dominant consensus for decades to cut the government out of health care. Research has shown that the dominant position now in the medical profession appears to be support for a single payer, which was anathema to the old AMA. So that’s a crucial sea change. Another important sea change in the politics of health care concerns the younger generations, the post-Boomers. While more recent generations of young adults may not want to be forced into buying health insurance but they do want to have insurance, and they want it to be simple. So the notion of some version of social insurance or health care that would be inclusive, a so-called “Medicare for all”, has a much friendlier reception than in my generation, the Boomers. But I don’t think that these things are sufficient to bring us to a fundamental reform of our health care financing system. I do honestly feel that it’s going to take a mega-crisis to move us in that direction.
When the ACA was signed into law in 2010, it was predicted that the Medicare Hospital Insurance Trust Fund would go into insolvency by 2017, that there was a combination of the Boomers retiring and becoming Medicare eligible and health care inflation that was pushing Medicare to collapse. So when the ACA was passed into law, it had a number of provisions in it that stretched out the solvency of Medicare for another decade, to about 2030 and that was under the rather heroic assumption that all these provisions would be implemented and work as intended. All we’ve done with the ACA is we’ve bought time. It’s not only the collapse of the Medicare Trust Fund, it is also the unending health care inflation that affects the continued viability of employment-based insurance and Medicaid for the low income and poor. National health care expenditures are now knocking on the door of 20% of the GDP. Ultimately, it is these things that are going to push us to more fundamental financing and delivery system changes.
Certainly one solution to the solvency of Medicare as a whole and the Medicare Hospital Insurance Trust Fund in particular, is in fact a “Medicare for all” solution that massively infuses the social insurance for health care with both the payroll taxes of younger adults and also their relative health. [laughs] Aside from its potential for stabilizing the long term solvency of Medicare, this is also consistent with Rawls’ recognition of the relationship between intergenerational interdependence and his principle of reciprocity. The young after all will have their turn at being old. In sum, this is both fiscally sound and just.
So it is sort of pessimism and optimism. The pessimism is that the ACA is not a long-term solution, we’re headed to a cliff. We’ve only prolonged the viability of our health care financing structure, and a lot of people could get hurt on the road to collapse. But the optimistic part is that we have a history as a country of finally making fundamental reforms where and when there is an imperative need to do so. And in one way I’m sort of betting my life on it, because I’m 65! I’m relying on the solvency of the Medicare Trust Fund when I retire, that’s going to be my insurance. Maybe that’s a reason for my optimism too.