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U.S. Politics 'Medicare for All’: These are the patients at stake in the U.S. battle over universal health care

Dan Keller talks with a dentist before a procedure at a Remote Area Medical mobile clinic in Harrisonburg, Va. RAM stages pop-up facilities in low-income regions of the United States, and in March it came to the Rockingham County fairgrounds to offer dental, medical and eye-care treatment to hundreds of people. Mr. Keller is here to have three teeth extracted.

Photography by Parker Michels-Boyce/The Globe and Mail

In the predawn darkness of an Appalachian winter, almost 400 people crowd around the front doors of a cavernous metal building at the Rockingham County fairgrounds waiting for a rare opportunity to get health care. They spent the night in the adjacent gravel lot, sleeping in their cars or pacing in freezing temperatures, staking out a place in line for the two-day free clinic.

There’s George Morris, a 56-year-old roofer. He arrived at midnight after walking for 14½ hours. His decaying teeth have been bothering him for years, but he couldn’t afford to deal with them – in part because he’s still paying off a hospital bill from 1999, when he broke his neck diving into a swimming hole. “I’m just tired of hurtin’,” he says.

Reba Head, meanwhile, has sleep apnea so severe she fears dozing off behind the wheel of her car. She has no health insurance, so the condition has gone untreated. “I don’t take anything for it,” says Ms. Head, 32, who works for a temp agency. “My body shuts down.”

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Carl Valdez, 30, has had knee trouble for the past couple of years. His insurance has been intermittent because he switched jobs, from trimming trees to working in a poultry plant, so he hasn’t got it checked out. “I can feel it grinding and popping when I move my leg,” he says.

At 6 a.m., the doors open, and a volunteer starts admitting patients. The clinic is run by Remote Area Medical, an NGO that stages pop-up facilities in low-income places such as this, the Shenandoah Valley, on the western edge of Virginia.

Percentage of people in the U.S. with

and without health insurance

Population as of March of the following year

Population as of March of the following year

Population as of March of the following year

Insured 91.2%

Not insured 8.8%

28% of insured are underinsured*

*Underinsured defined as having unaffordably high out-of-pocket costs, such as deductibles or co-pays, to use their health insurance.

THE GLOBE AND MAIL, SOURCES: U.S. CENSUS

BUREAU; THE COMMONWEALTH FUND

Percentage of people in the U.S. with

and without health insurance

Population as of March of the following year

Insured 91.2%

Not insured 8.8%

28% of insured are underinsured*

*Underinsured defined as having unaffordably high out-of-pocket costs, such as deductibles or co-pays, to use their health insurance.

THE GLOBE AND MAIL, SOURCES: U.S. CENSUS

BUREAU; THE COMMONWEALTH FUND

Percentage of people in the U.S. with and without health insurance

Population as of March of the following year

Insured 91.2%

Not insured 8.8%

28% of insured are underinsured*

*Underinsured defined as having unaffordably high out-of-pocket costs, such as deductibles or co-pays, to use their health insurance.

THE GLOBE AND MAIL, SOURCES: U.S. CENSUS BUREAU; THE COMMONWEALTH FUND

The United States remains the world’s only developed country without universal health care, and the results are stark. Census Bureau statistics show 28.5 million Americans have no health insurance. Another 41 million are “underinsured,” meaning they cannot afford the out-of-pocket co-pays and deductibles to use their plans, according to an estimate by health research group the Commonwealth Fund.

Now, momentum is building for reform, branded “Medicare for All” by supporters. Considered a fringe idea in the Democratic Party just a few years ago, government-funded universal health care has the backing of more than half the dozen contenders for the party’s 2020 presidential nomination. A network of activists is running a nationwide campaign to build support for the plan. And a Reuters/Ipsos poll last summer found 70 per cent of respondents supported it – with even a majority of Republicans backing the idea.

The Democrats found success in last year’s midterm elections by campaigning on health care. They signalled this week that it will be their policy priority in Congress.

But an examination of why the United States has repeatedly failed to create universal health care reveals the enormous pitfalls its advocates face. For one, powerful interests – the insurance industry, hospitals, businesses, some doctors – have thrown hundreds of millions of dollars into derailing previous efforts. For another, many Americans embrace a small-government ideology that mistrusts any expansion of the state. Lastly, the U.S. system of checks and balances makes it difficult to enact major programs, requiring protracted negotiation between the White House and Congress, even when both are controlled by the same party. And it’s not even clear the Americans who would benefit most from Medicare for All, including the people waiting in the cold in Rockingham County, care enough about the idea to vote for it.

The United States stands at a crossroads. Universal health-care advocates see the chance of a lifetime to push ahead with the largest expansion of the country’s social safety net since the New Deal. But every conceivable force – including U.S. history itself – stands ready to stop them.

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Early in the morning, a sign at the entrance to the Rockingham County Fair advertises the two-day clinic.

This man got his numbered ticket at 3 a.m. The tickets are first come, first served.

Carolyn Fink is one of the would-be patients who waited overnight in their cars, with zero-degree temperatures outside. Others spent hours walking to the clinic.




On July 30, 1965, Lyndon Johnson signed two new programs into law. Medicare would provide government health insurance to senior citizens, while Medicaid would cover the poorest of the poor. The president marshalled his legendary deal-making skills to get the measures through, cajoling legislators to pass the bill and pressing the American Medical Association (AMA) to ensure physicians would treat people under Medicare.

Mr. Johnson intended his programs to ultimately lead to universal health care. But even someone with his political savvy didn’t feel confident he could get there all at once.

“One, it was ‘socialized medicine’ – remember, that’s the height of the Cold War. And two, the doctors were very powerful then – and they were completely opposed,” Joseph Califano, Mr. Johnson’s domestic policy chief, recalls in an interview.

The next president, Richard Nixon, tried a different route. He pitched a public-private health-care plan centred on obligating companies to provide insurance for their employees. But before a bill could move forward, Mr. Nixon resigned over the Watergate scandal. His successor, Gerald Ford, didn’t push the health-care issue.

“We sort of just ran out of steam, and Ford didn’t have the interest or the leadership capacity,” says Stuart Altman, the civil servant who helped draft Mr. Nixon’s proposal. “There are limited periods of time when something can get done, and it doesn’t take much to kick it off the rails.”

The next attempt wouldn’t come until 1993, when Bill Clinton appointed Hillary Clinton to steer a complicated legislative package. Among other things, their proposal would have created a system for managing competition between insurance companies.

Insurers launched an all-out attack. In a series of ads, a couple dubbed “Harry and Louise” fretted they would end up with worse coverage and became increasingly confused by the plan’s complexity. Public support weakened, and congressional backing evaporated.

Barack Obama’s Affordable Care Act, popularly known as Obamacare, involved a suite of reforms to make it easier for people to buy private insurance while also expanding Medicaid for low-income people. Originally, Obamacare also included a “public option” – a government-run health-insurance plan open to anyone, which would have competed with private insurers.

Mr. Obama was slammed by all three forces that had bedevilled his predecessors.

Businesses lobbied against Obamacare provisions that would push them to provide their employees with coverage. The AMA opposed the public option. Insurance companies objected to both the public option and rules forcing them to cover people with pre-existing medical conditions.

Republican politicians warned that Obamacare represented unreasonable government interference in private enterprise. They stirred up fears that people who already had insurance would see their premiums increase, coverage scaled back or somehow lose the ability to choose their own doctors.

And it took just one senator to kill the public option. Joe Lieberman insisted he would not vote for a plan that contained the provision. Mr. Obama needed Mr. Lieberman’s support to avoid a Republican filibuster, so the president acquiesced.

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The rest of Obamacare passed, extending health-care coverage to 20 million more people.

Kathleen Sebelius, Mr. Obama’s secretary of health, says the administration got as much as realistically possible. Even bringing in measures to control prescription drug prices – something most Democrats agree on now – didn’t have enough congressional support at the time to include in the bill.

“The president chose to go as far as we could go, in spite of the fact that there were lots of people in 2009 and 2010 saying, ‘Don’t do health care at all’ or ‘Do a smaller program,’” she says. “People were certainly not ready to embrace some of the concepts that are very widely accepted today.”

President Donald Trump failed to get an Obamacare repeal bill through Congress two years ago and is now backing a legal challenge by 20 Republican state governments to have a court scrap the law.

Meanwhile, other wealthy countries have all achieved universal health care through a variety of methods. These range from Britain’s full-on socialized medicine, in which many doctors are state employees, to heavily regulated and subsidized private insurance in Switzerland to Canada’s single-payer system, in which doctors maintain their independence but patients are all covered by government insurance.

Some of the differences that allowed other countries to do what the United States hasn’t are obvious. It is easier for a government to pass legislation in a parliamentary system such as Canada’s, for instance, where strict caucus discipline makes it far less likely that a handful of legislators will derail a major bill.

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But Robin Osborn, the director of the Commonwealth Fund’s international program in health policy, points to something more elemental.

“What underpins all of those universal models is a social contract, a broad consensus that everyone is entitled access to affordable health care, and that the government has a role in making that happen,” she says. “We don’t have that here in the United States.”




At the clinic, volunteers in the dental section attend orientation before the first patients arrive.

About 40 dentist chairs have been set up for patients having teeth extracted or cavities filled.

At the registration desk, volunteers surprise Hawanaz Wais by singing Happy Birthday to You.




The exhibition hall at the Rockingham County fairgrounds is a hive of activity as the clinic gets under way. Along one wall, black curtains partition the space into makeshift examination rooms. Next to that, more than two dozen dentist chairs are lined up, each with someone getting teeth pulled or cavities filled. Other patients sit on folding chairs waiting their turns or recovering.

“It’s good that we have these clinics," says Wayne Hachey, a former military doctor who regularly volunteers with Remote Area Medical. "It’s bad that we need these clinics. In a country with the resources we have, not to have universal health care, it’s a shame.”

The consequences of that gap are clear. A 2017 Commonwealth Fund study ranked the U.S. health-care system last among those of 11 high-income countries, with more than double the death rate from treatable illnesses of Switzerland and almost triple the infant mortality rate of Sweden. For every 100,000 children born in 2015, 26.4 American mothers died in childbirth, according to data compiled by The Lancet. The number for the United Kingdom was 9.2; for Canada, 7.3; Norway, 3.8.

Despite these results, U.S. health care is more expensive than that of most of its peers. World Bank figures show the United States spends almost 17 per cent of its GDP on health care, compared with 10.4 per cent for Canada and slightly less than 10 per cent for the United Kingdom.

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Universal health care’s newfound momentum has a few explanations. Bernie Sanders’s 2016 presidential campaign revealed that such a policy is a good way to motivate the base. Branding the proposal “Medicare for All" is effective, linking it to an existing, familiar program. And the idea has polled well: Last year’s Reuters/Ipsos survey found it was supported by 85 per cent of Democrats and 52 per cent of Republicans.

It has also helped that Mr. Sanders’s supporters spun off his 2016 campaign into a sustained effort to build support for his policies. In February, Medicare for All advocates held 150 “barnstorms,” or organizing events, across the country to launch a mass canvassing campaign. The goal is to reach voters at the door – as well as by e-mail and text message – to encourage them to lobby their members of Congress to vote for a universal health-care bill tabled by Congresswoman Pramila Jayapal.

“This is a perfect storm, where you have these different organizing methods, where you have different electoral politics and you have a health-care system that is really failing and people are really clearly seeing it fail,” says Kelly Coogan-Gehr, a Medicare for All campaigner with National Nurses United. “All of these are coming together at the very same time.”

But the campaign faces an uphill battle.

For one thing, the vested interests have not gone away. The pharmaceutical and insurance industries spent more than US$280-million and US$157-million, respectively, on federal lobbying last year, according to the Center for Responsive Politics, a government transparency group.

What’s more, Medicare for All’s proponents do not agree on what, exactly, it means. Mr. Sanders favours moving all Americans to a government-run health-insurance plan. Other presidential contenders, such as Cory Booker, want to leave private insurance in place while also creating a government plan.

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Polling by the Kaiser Family Foundation, a health-care research group, has found the policy’s popularity fluctuated widely based on such specifics. A single, government-run plan was favoured by 57 per cent of respondents, while 75 per cent backed a voluntary plan that would compete with private insurers.

Public attitudes on proposals

to expand Medicare and Medicaid

Strongly favour

Somewhat favour

 

 

Strongly oppose

Somewhat oppose

 

Allowing people between the ages of 50 and 64 to buy health insurance through Medicare

49%

28%

8%

10%

Allowing people who don't have health insurance through work to buy it through their state Medicaid program instead of purchasing a private plan

45%

30%

10%

9%

Creating a national government-administered health plan similar to Medicare that would be open to anyone and would allow people to keep the coverage they have

49%

24%

8%

16%

Having a national health-care plan, sometimes called Medicare for All, in which all Americans would get their health insurance from a single government plan

34%

22%

10%

32%

Note: Stacked bars may not add up to 100

due to rounding.

THE GLOBE AND MAIL,

SOURCE: KFF HEALTH TRACKING POLL

(CONDUCTED JANUARY 9-14, 2019.)

Public attitudes on proposals

to expand Medicare and Medicaid

Strongly favour

Somewhat favour

 

 

Strongly oppose

Somewhat oppose

 

Allowing people between the ages of 50 and 64 to buy health insurance through Medicare

49%

28%

8%

10%

Allowing people who don't have health insurance through work to buy it through their state Medicaid program instead of purchasing a private plan

45%

30%

10%

9%

Creating a national government-administered health plan similar to Medicare that would be open to anyone and would allow people to keep the coverage they have

49%

24%

8%

16%

Having a national health-care plan, sometimes called Medicare for All, in which all Americans would get their health insurance from a single government plan

34%

22%

10%

32%

Note: Stacked bars may not add up to 100 due to rounding.

THE GLOBE AND MAIL, SOURCE: KFF HEALTH TRACKING POLL

(CONDUCTED JANUARY 9-14, 2019.)

Public attitudes on proposals to expand Medicare and Medicaid

 

 

Strongly oppose

Somewhat oppose

 

Strongly favour

Somewhat favour

Allowing people between the ages of 50 and 64 to buy health insurance through Medicare

49%

28%

8%

10%

Allowing people who don't have health insurance through work to buy it through their state

Medicaid program instead of purchasing a private plan

45%

30%

10%

9%

Creating a national government-administered health plan similar to Medicare that would be

open to anyone and would allow people to keep the coverage they have

49%

24%

8%

16%

Having a national health-care plan, sometimes called Medicare for All, in which all Americans

would get their health insurance from a single government plan

34%

22%

10%

32%

Note: Stacked bars may not add up to 100 due to rounding.

THE GLOBE AND MAIL, SOURCE: KFF HEALTH TRACKING POLL (CONDUCTED JANUARY 9-14, 2019.)

“As a party, we have to be clear about exactly what we are talking about, and we have to be cognizant that if we can’t deliver over a certain period of time, our supporters are going to get angry and frustrated with us,” says Rodell Mollineau, a Democratic political consultant who was an adviser to the party’s Senate leadership when Obamacare was passed.

But Ms. Coogan-Gehr contends that health-care advocates have to push for an ambitious single-payer system if they want to generate enough excitement to motivate people to vote and lobby for reform.

“Incrementalist policy proposals are not going to cut it,” she says. “They are not going to move people to fight, to come together against the big problems that we are facing.”




Brendan Mendoza has his vision tested at the RAM clinic. All patients were able to receive medical care but had to choose between receiving vision or dental care.

Glasses are put on display for patients to try on.

Amanda Miller, a certified physician assistant, checks the eye movements of Eduardo Aguilar after he complained about recent loss of vision.




As Curtis Wiles waits his turn outside the Rockingham County clinic, the 67-year-old rhymes off the medical bills he’s had to pay over the past few years: a 2½-month hospital stay for his wife after open-heart surgery; a twisted ankle that forced him to leave his job changing tires at a truck stop; US$300 for an intake appointment with a family doctor’s office. “If someone came and grabbed my wallet, I’d feel less robbed than going to the doctor,” he says.

Still, Mr. Wiles – who supported Mr. Trump in 2016 – isn’t sure how he feels about universal health care. “I don’t know,” he says. “I didn’t consider health care when I voted.”

Dianne Harris also backed the President. The 65-year-old retired restaurant manager is getting tested for diabetes at the clinic. She doesn’t know what she’ll do if the result is positive: Supplies for managing the condition can run up to US$500 a month.

Ms. Harris says Medicare for All is “a good idea,” but won’t be voting for it any time soon. She describes herself as a “diehard Republican” because she is against abortion. And she agrees with other aspects of Mr. Trump’s agenda.

“The illegals come in here and they get the health care and the food stamps, and here I am and I have to make a choice between drugs and rent,” she says.

Ms. Harris is wrong, of course. Undocumented immigrants actually have less access to health care and food subsidies than U.S. citizens.

But she and Mr. Wiles embody some of the most difficult hurdles for health-care advocates.

Americans often vote against their economic self-interest. The two states that proportionally gained the most health-care coverage under Obamacare, for instance – Kentucky and Arkansas – both voted overwhelmingly against Mr. Obama and Ms. Clinton.

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And many people who would directly benefit from universal health care are politically disengaged.

There are, in fairness, some exceptions.

Doug Huffman, 54, who is chatting with Mr. Wiles outside the clinic’s front door, says Obamacare-regulated insurance plans offer “a better rate than anywhere else around.” And he is enthusiastic about the idea of Medicare for All. “Government-funded health care? Hell yeah!” he says.

But he is in the minority among people The Globe meets over the course of the day.

More representative is Seth Kauffman. A wiry, gregarious 29-year-old, Mr. Kauffman says his family could certainly use better health coverage. His mother is supposed to have quadruple bypass surgery but is putting it off because her insurance plan will not pay for her to stay in a hospital room.

Even so, Mr. Kauffman doesn’t have a fully formed view on Medicare for All.

“I haven’t paid much attention to it. If it’s anything that’s like Canada, then I’m all for it. But if it drains away the economy, then it’s not worth it,” he says. “We need something here. We’ve got shit health care.”

Patients at the RAM clinic wait to receive dental care.

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If you would like to write a letter to the editor, please forward it to letters@globeandmail.com. Readers can also interact with The Globe on Facebook and Twitter .

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