The Contentious ACA

Leticia Wiggins 

Welcome to History Talk Produced by Origins, a project of the public history initiative and the Goldberg Center and the Department of History at The Ohio State University. We hope you enjoy what you find.

 

Patrick Potyondy 

Okay, this is Patrick Potyondy, one of your History Talk cohosts and I'd like to welcome you to this month's podcast. It's safe to say there isn't much in the past four years that's created more political dissent than the Affordable Care Act. While this acrimony has built in recent memory. parts of this legislation are nothing new. As our recent Origins article explains Obamacare's legacy can be traced back even to the First World War and the creation of a health care system for military veterans.

 

Leticia Wiggins 

Hello, I'm Leticia Wiggins, your other cohost today and then this month's History Talk we'd like to reconsider the health care policies that have preceded the Affordable Care Act, putting the current contentions and historic context and we're lucky enough today to be joined by three experts. So, I'd like to invite them all to introduce themselves.

 

Tamara Mann 

Hi, my name is Tamara Mann. I'm a recent PhD in American history from Columbia University with a specialty in the history of old age and health policy. I'm currently an associate at the Humanities Institute here at OSU.

 

Sandra Tanenbaum 

I'm Sandra Tanenbaum. I'm a professor in the College of Public Health. I'm a political scientist, and I teach health policy and politics.

 

Dr. Steven Conn 

Hi, Steven Conn, and I'm a professor in the history department here at OSU and one of the editors of Origins magazine.

 

Patrick Potyondy 

Alright, thank you three for joining us today and welcome. And so, to begin a question in constant consideration is a political one of quote, "is this system socialist?" Has this always been a fear historically? And how has this fear stymie the creation of policies currently? And since I know you're chomping at the bit here, Steve, will throw this question to you first.

 

Dr. Steven Conn 

Sure. Yeah. It's so funny how, what a difference a little word can make. It's certainly the case that over the past hundred, even hundred plus years, if you call anything socialist, that's the kiss of death in American public life, but that's not really, I think, the best way to think about it. The way to think about this is to is to remember that the federal government has always been involved, certainly over the last century in health care one way or another, in some ways, it's one of the most subsidized areas of American life since the late 19th and early 20th century. So, it's not really a question of whether the government is going to be involved in the delivery of health care. It's really how it's going to be involved. And that's always been true.

 

Tamara Mann 

I would just like to add, though, I think the word socialism has worked very well for a very long time. And it's sort of remarkable why so you know, the AMA hired advertising firm Whitaker and Baxter with the purpose to malign the national health insurance. They came up with the phrase socialized medicine and it just hasn't gone away. And the question is why? Why is it still such a powerful phrase, it doesn't really apply anymore?

 

Sandra Tanenbaum 

Yeah, it was especially potent, just before Medicare was passed. After the Second World War, during the Cold War, calling something socialist had an extra oomph to it. Yeah, and Medicare struggled to be passed under that moniker.

 

Leticia Wiggins 

Great. So, to move on much of this issue with the Affordable Care Act comes with the question of, who is a public charge? As they say, in this World War One era. So, the Affordable Care Act marks a breakaway from the public charge model. So, what do you think finally caused this shift away from it? And I'd like to address this question to Tamara and maybe to define also what a public charge would be in this case too.

 

Tamara Mann 

Well, I think Jessica makes a really great point in her Origins piece when she says, you know, the ACA marks a shift away from the 20th century model of offering individuals federal assistance based on membership and a clearly definable group of citizens. So, the ACA, I think this is a really interesting question, because the designers of Medicare in the 1950s absolutely believed that this policy would be the first step towards national health insurance, Medicare would start an incremental approach that would eventually include all groups like voting or even Social Security. So, you know, one way to read the ACA is this finally happened. Another way to read it is that this step-by-step approach to federal health insurance, arguably enhanced the power of private insurers and failed to ensure cost control mechanisms created a financial crisis of such epic proportions that we needed something, and that the ACA was the best feasible option and the least amount of structural change. So I think these two ways of viewing the ACA is a way of explaining the difference.

 

Dr. Steven Conn 

Of the direct delivery of health care to citizens through the creation of a veteran's health care program after the First World War. The definition here is that there are a group of people who, because of a special category are deserving of special treatment by the government. And so, what evolved over the 20th century is the growing set of boundaries around who gets to be considered a special category and I think, so that's how the evolution of the notion of a public charge I think has has grown from the 19th century poor laws up through the 21st century ACA.

 

Sandra Tanenbaum 

I would quibble a little bit with the notion that the ACA leaves this public charge business behind. One of the most important aspects of the ACA is the Medicaid expansion, which is very much a mat. So, who's deserving is now in the states that are taking advantage of the expansion, who's deserving is now defined entirely by poverty level, and not by membership in some other group like children or the elderly. But people under 138% of poverty are the new public charges. Now, the exchanges are different are different part of the ACA and that has to do with insurance regulation. But there is this very substantial and the Medicaid signup rates are very, very high. Right? This is a really important addition to the public charge.

 

Patrick Potyondy 

Great. So related is this question of who is deserving of government help. And one creating a lot of debate, especially with those who say Obamacare is a, quote, disincentive to work. Are there instances of this concern obvious in the past? Or is this a new phenomenon? and Sandy we'll direct this question first to you.

 

Sandra Tanenbaum 

This is always a question. If you give people something, they're going to stop working. You know, the creation of bums is a very repetitive theme in all of our social policy in this country. So, it's absolutely not.

 

Dr. Steven Conn 

Yeah, and you know, I teach a course in the 19th century, and you can find this rhetoric in the 19th century as well. So this this is a dare I say it, a tired trope that that gets trotted out fairly regularly that any kind of public assistance is necessarily going to create dependence and it's going to create laziness and so on and so forth.

 

Tamara Mann 

Can I just jump in here because I wonder, I feel like it's an easy charge to dismiss for liberals and you know, Goldwater leveled this to people when they were starting to create Medicare and his fear was basically this, if the government is taking over responsibility for the elderly, why won't children abandon their responsibility? And listen, there were state laws basically saying children had to take care of their parents. We're seeing it in Japan now.

 

Dr. Steven Conn 

In China, that's right.

 

Tamara Mann 

Yeah. Yeah. In China. I think also, I think what's interesting is, it's very easy to dismiss it and say, that's totally ridiculous. But there is the rise of nurses. There, there are moments in American history where you see that this is a real conflict. Right. And I don't think it's fair to just dismiss it. And there might be a way we could more carefully invest ourselves in this question.

 

Dr. Steven Conn 

That I think that's a good point, because that raises another piece of this conversation that I, at any rate, haven't heard much about in the four plus years that we've had this debate over the ACA, and that is to say that those people who are an advocate of national health program of one sort or another think health care is something we all need and deserve. Those people who have opposed it have trotted out a set of arguments about the marketplace or about individual responsibility or family responsibility and so forth. And I think what has gotten lost a little bit is that over the course of the 20th century, our expectations of what health care means have changed entirely. So that 100 years ago, it is perfectly reasonable to expect families to take care of elderly and retired parents, because the life expectancy was about 62 years old. Now the life expectancy is well into the 80s. We're seeing problems now that we've never really experienced, we no track record here. We have no experience dealing with Alzheimer's and all these other sorts of things. So our expectations have shifted, and that has, I think, also necessitated a change in how we access health care.

 

Sandra Tanenbaum 

In addition to which I don't think there's much evidence that people abandon their elderly family members, the vast majority

 

Dr. Steven Conn 

We just joked about it a lot.

 

Sandra Tanenbaum 

The vast majority of long-term care is provided by daughters and daughters-in- law. Sometimes give up their jobs who have children in college. So, I don't think I mean, Goldwater may have worried about it. But I don't think there's much.

 

Tamara Mann 

And I, no. But I think that there was more of, I think people who were trying to support Medicare engaged with him at that in the 50s and 60s. And I think what they said is, listen, we're giving this to middle aged children, we want them to be able to support their parents. And I think just having that kind of engagement with it, is this is going to promote self-reliance, or is this paternalism is actually kind of helpful, and I don't think you see enough of it in the ACA debates, but I totally agree. I completely agree with that.

 

Dr. Steven Conn 

But certainly during the campaigns, both in 2008 and 2012, there were politicians who talked about the alternative to this program as being somehow the community would have a bake sale when somebody was uninsured. And well, you know, if you have cancer and your bills are running $150,000, this is absurd. But that wouldn't have been the case 50 years ago, 100 years ago, because medical technology, medical treatments have changed so dramatically, that that has necessitated a change in how we can pay for and access health care.

 

Sandra Tanenbaum 

In addition to which our political system has created a health care system where the prices are so high.

 

Dr. Steven Conn 

Yeah, yeah, yeah.

 

Sandra Tanenbaum 

So much higher than everybody else's that even if this technology weren't more sophisticated.

 

Dr. Steven Conn

Yeah, that's a good point.

 

Sandra Tanenbaum

We have led to higher and higher and higher prices.

 

Tamara Mann 

Elizabeth Bradley has a new book coming out on the healthcare paradox. And you know, Ezekiel Emmanuel came to campus a few months ago, and he gave, you know, he's like, we absolutely need the ACA because it's $2.8 trillion a year on health care. And that puts us just in the minority internationally for other like, you know, similarly developed countries, we're spending 30%, they're spending 9%. And then Bradley comes in and she basically says that our numbers are wrong, and that what we should be looking at is the combination of healthcare spending and social services and treating basically healthcare spending outside of housing spending and, you know, preventative care and early mental health initiatives. That if we actually evened out the numbers, we're spending about 25%. They should all the National Health investment countries like Sweden, England are spending 25%. That's just wondering what you guys thought about that. And if we're actually, if we're actually kind of just going about this whole debate a little bit off a little bit wrong.

 

Sandra Tanenbaum 

Well, I think what you're saying what she's saying is true, and they get a big bang for their buck that we don't. So, we create problems with our lack of social spending that sometimes we then fix in the expensive health care system. Yeah, sure. If you were to even out you know, what is our safety net? We wouldn't look we wouldn't look like such a big spender. And we have the results to prove it.

 

Patrick Potyondy 

I'm wondering is this part of the ACA plan to kind of reduce costs is trying to get at some of those kind of preventative measures that President Obama has highlighted from time to time is that part of to try to cut off some of that higher spending later in life?

 

Sandra Tanenbaum 

Well, the Congressional Budget Office refused to score any of the preventive of measures in the ACA, because the evidence that it will actually save money is too weak, at least for the bean counters to say, I think the cost issue not to take exception to Zeke Emmanuel, but I think the cost issue in the ACA is hardly dealt with. I think it's a coverage bill. I don't think it's a cost containment bill.

 

Tamara Mann 

I think that conflation is something that really goes back to, you know, Jessica's article on Veterans Health and Medicare, which is, we've conflated for a very long time in this country, health care and health coverage. So that we are we had an argument that we were talking about health care leading up to the ACA, and I totally agree, we were really talking about health coverage.

 

Dr. Steven Conn 

Well, and again, the question of cost is not an absolute question. It ought to be considered relative to outcomes. And so if $2.8 trillion gets you the outcomes, the health outcomes you want, then it's a perfectly appropriate amount of money to spend. If it doesn't get you the outcomes that you want, then, then it's not the appropriate money- amount of money to spend that I've got to be balanced in here as well.

 

Leticia Wiggins 

Great. Well, I know that this has already been hit on in some, in some ways with the last question. But we were wondering also how do health benefits for the elderly tie into the debates both past and present over the federal role on health care and reducing policy.

 

Sandra Tanenbaum 

The elderly are excused, because they don't work. So Deborah stone says that every society is divided into a work based sector and a need based sector. And where you draw the line is individual to that society who gets resources on the basis of need, who gets resources on the basis of work? The elderly pretty traditionally have been in that- we don't expect you to work anymore. At least at some age, maybe it won't be 65 much longer, but so I would say that the elderly are pretty much outside the ACA, and they're pretty much settled as a deserving. I mean, not every member of Congress would agree.

 

Tamara Mann 

I'll just say although you know that the policy, the policy crafters of Medicare, you basically use the elderly. I mean, they wanted national health insurance. This was supposed to be an incremental approach. The elderly were supposed to be the first group children are supposed to be next. And this idea of lifting up the elderly, forever in American society as a special group. I don't even know I don't really think that was the intention. And I do think that the ACA, in some ways is a reaction to some of the early problems with Medicare, which were no cost cutting mechanisms, really, I mean, incredible healthcare, I mean, the healthcare costs just skyrocketed after Medicare. But now I think the great news is Medicare is being used. We don't have a public option anymore in the ACA and Medicare is really the think tank I think for cost control mechanisms now.

 

Sandra Tanenbaum 

it will do something about prices. I mean, the one the CBO said that the one prayer for cost containment and here Medicare's very important is the independent payment advisory board which may be repealed because there's a lot of congressional objection both on both sides of the aisles. And this is a panel that- an appointed panel that isn't running for office where the health care community is raising funds for the for the run, this independent panel will make reimbursement changes. And Congress has a very small window to undo what this panel does. And so Congress is irate because they've had a responsibility removed from their plate. But this was the one possible cost saving mechanism in the mind of the CBO.

 

Dr. Steven Conn 

But you know, I also I would just interject that if you take Medicare and social security a generation earlier, also targeted at the elderly, the retired as a package, it worked, in the sense that in the 1930s, the single poorest demographic sub group in American life were those people over 60. That isn't true anymore. Alas, its children under five now, but the point is here was a set of programs designed to attack that particular problem, the problem of the impoverished elderly, and it succeeded in creating a much more prosperous retired population, and one that now lives considerably longer.

 

Sandra Tanenbaum 

Unfortunately, that package took 30 Years.

 

Dr. Steven Conn 

That's correct. That's correct.

 

Tamara Mann 

And I don't think it worked right away. I mean, the great moment was in '72, when Nixon lifted the 20% rise in monthly benefits. I think until then was- and I think it also reminds us that it takes a long time to get the policy right.

 

Dr. Steven Conn 

 Yes, I think that's exactly right

 

Tamara Mann 

I mean, I think that's very optimistic.

 

Dr. Steven Conn 

And I think Johnson understood that entirely with Medicare was that it didn't matter really for him, all the details in this bill, he was going to get this bill through and then we're going to fix it later. And it has been tweaked and poked at and so forth.

 

Patrick Potyondy 

Building On the conversation here, part of the comprehensive health insurance reforms includes claims of lower health care costs, and also claims to guarantee more choices to quality care. And Jessica Adler's piece, the government health care provided for World War One veterans was portrayed at the time as less of a choice than as a necessary crutch. What does this element of potential choice currently bring to the table? And let's have Steve take on this question first.

 

Dr. Steven Conn 

What interested me about the debate over health care choice, as this bill was being proposed, and then fought over was the idea that a national health program of any kind was necessarily going to take consumer choice away somehow that the government was going to make this decision for you. And what I found really remarkable about that particular line of argument was that it did not acknowledge that choices were already being made for all of us in private insurance programs already. We didn't have that kind of choice that was that they were pretending we had. And so the threat that it was somehow going to be taken away struck me as very hollow. I think that the, the, you know, the question of choice is deeply important to Americans as we view health care as yet another of our consumer options. But I'm actually a little troubled by the idea that we ought to treat it that way that really all we are our healthcare customers. We're not actually patients. I think when you reduce the interaction here to the consumer transaction, I think you run some risks that are I'm uncomfortable with.

 

Sandra Tanenbaum 

I think you have to make a distinction between choice of insurance and choice of provider.

 

Dr. Steven Conn 

Yes.

 

Sandra Tanenbaum 

The ACA is actually creating economic incentives, financial incentives for healthcare organizations to limit your choice of provider. And the only people who will have more choice are people who can buy on the exchange and that's not everybody and people whose State level exchanges are rich with options. And that's not every exchange. So I think I'm not sure how much choice the ACA gives you.

 

Tamara Mann 

And I also think getting rid of the public option got rid of the major choice. I mean, your choices are now private insurance, private insurance, private insurance.

 

Dr. Steven Conn 

Yeah. And you also bring up another peculiarity when we compare this to other systems and other developed nations, that any system in this country has to be done 50 different times because insurance is regulated at the state level, not at the federal level. So we've got 50 different versions of this that have to play out. That also strikes me I'm not an expert in federalism or anything like that, but it strikes me as tremendously inefficient to have to have, what you do in Montana is not the same thing you do in Idaho, which is not the same thing you do in Washington State.

 

Sandra Tanenbaum 

And don't forget the 52 Medicaid program. Everyone went to

 

Dr. Steven Conn 

Sure sure. Right, right.

 

Tamara Mann 

I brought in this Atul Gawande quote. I loved it so much because it basically he's trying he's trying to make a case for the ACA in 2012, even though it's obviously such a Band-Aid on a complex, possibly dysfunctional system. And he goes, "Yes, the American Health care is an appallingly patch together ship with rotting timbers, water leaking and mercenaries on board, and 15% of the passengers thrown over the rail, just to keep it afloat. But hundreds of millions of people depend on it"

 

Dr. Steven Conn 

That's right, there you go.

 

Sandra Tanenbaum 

for their incomes as well as their health care.

 

Leticia Wiggins 

We just would like to thank the three of you. We'd like to thank Steve, Sandy, and Tamara for joining us today. It's been a really great discussion about the ACA. So thank you, all of you for joining us.

 

Dr. Steven Conn 

My pleasure.

 

Sandra Tanenbaum 

Thank you.

 

Tamara Mann 

Thank you.

 

Leticia Wiggins 

This edition of the Origins podcast History Talk was brought to you by the public history initiative and the Goldberg Center in the history department at The Ohio State University. Our main editors are Steve Conn and Nicholas Breyfogle. Our executive producer is David Staley. Our website manager and technical advisor is Mitchell Shelton. Our audio editors and cohosts are Patrick Potyondy and Leticia Wiggins. Find our podcasts and more at our website origins.osu.edu Thank you for listening!