Constance A. Nathanson is an American historian of public health. She recently wrote an essay for The Lancet that explains why the public option is such a hot button – one that threatens to confront us with the underlying issue of health inequality.
Early in the twentieth century, industrialized nations – with the glaring exception of the US – acknowledged that national governments had a responsibility to protect the health of the poor. In practice, this took the form of health insurance, wholly or partially paid for by the state. The motivation was primarily self-interest. Contagious diseases don’t distinguish between the rich and the poor. Also, there was a fear that poverty would provide a breeding ground for social revolution.
Death rates among the poor have declined since the days when living conditions were highly unsanitary and working conditions extremely dangerous. Health inequalities persist, however. In the late 20th century, each country has had a unique response to this issue, depending on its moral beliefs and political system.
While the historical context has changed, the issues at stake–the meaning of inequalities, what should be done about them, and who should do it–are very much the same as in the past. Are health “inequalities” a problem of the poor (and thus soluble by changing poor people’s circumstances or behaviour) or are they an effect of rigid patterns of social stratification (requiring that resources be redistributed)? Are they “voluntary”–the result of bad choices (“booze and fags”)–or “involuntary”–the consequence of oppressive social structures? Should inequalities be framed as “disparities”–mere differences that may or may not be the result of human action–or as unacceptable “inequities”? And finally, who “owns” health inequalities? Are they–as in the 19th century–a public health problem or are they a medical care problem? Are they a private problem or a public problem?
These are not simply scientific questions to be answered by medicine or public health experts. They are political questions that are ultimately addressed in the voting booth.
The truth that will not speak its name
In the US, the federal government is not expected to reduce health inequalities. By default, health inequities have been left to a public health system, which has become a caretaker for the poor. Nathanson writes (emphasis added):
Many Americans are perfectly content with a two-tiered system that renders not only health inequalities but also the costs of the system that perpetuates those inequalities largely invisible. Acknowledging health inequalities as a serious public problem would be a first step towards accepting government ownership of the problem and government responsibility for addressing it–a path that opponents of health-care reform have no wish to tread. And so the current battle over health-care reform is essentially a battle over ownership and disownership. Only in the light of this underlying battle is it possible to understand the intense controversy generated by “the public option” (a government-run insurance scheme to compete with the private insurance market was included in several of the early bills before Congress), an option that would legitimise and institutionalise “public” responsibility for medical care.
Even if Congress manages to pass some version of health care reform this time around – even if they use reconciliation and include the public option — that doesn’t end the battle. Just as British localities resisted the Public Health Act in 1853, states’ rights advocates will reject government imposed health reform. It’s already happened in Virginia.
The USA has an enviable public health infrastructure. What it does not have is universal medical care, and my country’s record on health inequalities is abysmal. Although Americans may prefer to promote health-care reform for every other reason–reducing health-care costs, curbing rapacious insurance companies, making insurance affordable–the truth that will not speak its name is that adopting some form of universal health care is the USA’s last best hope for reversing health inequalities: perhaps not a social revolution but nonetheless revolutionary.
Inequalities in matters of health are a measure of the decency of a society. In 2007, 10.6 percent of white, non-Hispanic children were living in poverty. The number for black and Hispanic children was 64.5 percent. As Martin Luther King put it, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
If we had any self-respect, we would be ashamed.
“How come you’re rich and I’m poor?”
“Mum and Dad have highly paid jobs working on that very problem”
Source: Stefan Dercon
The indignity of the waiting room
Health inequities: An inhumane history
Déjà vu: Historical resistance to the inequities of health
Health care inequality: The US vs. Europe
This mess we’re in – Part 2
This mess we’re in – Part 3
(Hover over book titles for more info. Links will open in a separate window or tab.)
Constance A Nathanson, Who owns health inequalities?, The Lancet, January 23, 2010
Timothy S. Jost, J.D., Can the States Nullify Health Care Reform?, The New England Journal of Medicine, February 10, 2010