Health care has been one of the defining political debates of the last decade. With the Senate deadlocked on repeal or reform of the Affordable Care Act, tensions continue to rise on both sides of the aisle. Here, Julia Lynch, Associate Professor of Political Science, provides a broader context for public health and international health policy, and also discusses the social inequalities she says rig the system.
How does your field of research relate to the current health care debate?
Julia Lynch: My background is as a scholar of comparative social policy, so I've also looked at countries outside of the U.S., mainly in Western Europe. I'm interested in health care policy, but also in the politics of public health and population health.
Health and illness are very strongly socially patterned. If you don't have access to health care, that's a horrible thing because most of us agree that you should be able to go see the doctor when you're sick. But the real issue for population health is that the average level of health of a population group is very closely related to its members’ income, to their education, to their employment status, or to their employment history. It's related to their race and ethnicity, and can also be related to things like their disability status.
What factors lead to these inequalities?
JL: One factor is material resources. If you don't have adequate funds, it's harder to buy the things that make you healthy, like healthy food or decent-quality housing that doesn't have heating problems or problems with damp, membership in a fitness club—all these things cost money.
Another reason for the social patterning of health is the fact that there's inequality in society. We live in a hierarchical society. There are richer people and poorer people, Whites and non-Whites, able people and people with disabilities. Being on the bottom of a social hierarchy is hard on primates. Biologists have identified a stress-cortisol pathway that leads from the stress of being low on a social hierarchy to physical effects on the body: the ongoing, chronic stress of being in a socially subordinate position can leads to extra stress on bodily systems, and these are things that make us ill.
What impact has recent policymaking had on these issues of inequality?
JL: In the U.S., we have a hugely stratified society to begin with, which in and of itself causes health inequalities. Then you layer on top of that the health care system, which exacerbates the worst tendencies that are already there in the system in terms of generating ill health because you have to be able to pay in order to get health care. The Affordable Care Act (ACA) was designed to try to mitigate inequality in access to health care and quality of health care according to your ability to pay. People talk about the R word: rationing, which is this horrible thing in health care. But we ration health care in the U.S. all the time, it's just that we ration it by ability to pay instead of some other more transparent mechanism.
We don't live in a society that looks like most of the West European societies, where social solidarity is a value that people would recognize as one of the foundation stones of society. Social solidarity is not necessarily something we value in the U.S. I think both the broader system of stratification and the stratification that occurs within the health care system, they both come from the same place. Politics and the political preferences of the people cause us to have the policies that we have, but once policies are in place, the policies often feed back into public opinion. Basically, Americans learned not to want institutions of social solidarity, whereas, around the two World Wars, Swedes and British and French people learned to want solidarity because they had institutions that produced that and they began to take those for granted as a part of their society.
Why is it so hard for the Republicans, who have the majority, to pass health care reform?
JL: Republicans don't want an individual mandate, which is one of the key underpinnings of the ACA. And once you take the individual mandate away, it's very hard to make anything else work. The reason they don't want an individual mandate is they don't, for I think largely ideological reasons, believe in the idea of social insurance. They see it as an assault on individual liberty to say that we all have an obligation to pay into a system that will make the society better off as a whole, even if we as individuals at any given moment aren't benefiting from it.
That, I think, is a key reason for why they're having so much trouble. That and rolling back the tax increases on the very wealthy which were also part of the ACA. The mandate and rolling back taxes seem to be the two non-negotiable pieces for them. Congressional Republicans are having a lot of trouble coming up with a piece of legislation that can be scored by the CBO in a way that it will pass muster. Without the fundamental idea that this is a health care system for everyone, and everybody pays in, and everybody gets the benefit from it, the whole thing just doesn't work. They cannot produce a plan that is not going to strip health insurance from millions and millions of people, and that also meets the criteria that they've set out.
There’s also been a huge amount of mobilization against members of Congress in their home states. Even people who might not have supported it beforehand are now coming out and showing up at town hall meetings, saying, "the ACA saved my son's life or my neighbor's life or whatever." People are more likely to agree about the need to preserve access to health insurance than they are to agree about a whole lot of other things that don’t affect them so directly.
President Trump has suggested the ACA will fail if left to its own devices. What is your opinion on this?
JL: I don't think there's an easy answer to that. There's some misinformation about what's happening in insurance markets. Some of the press coverage has been misleading in the sense that people talk about how premia have gone up by X percent. Actually, premia always go up by X percent per year. The question is, are premia going up faster than they would have been going up otherwise? Are they at a higher level than before the ACA was implemented?
It is true that in some states, and in some localities, there are far fewer insurance plans available on the exchange than there were at the beginning of the process, and than policymakers had anticipated. That's partly, in some cases, because insurance companies have been acting in bad faith and have been pulling out of markets. I think a more significant cause, though, is that Marco Rubio spearheaded the effort to take out of the ACA many of the provisions that had sought to protect insurers as they entered these new markets. Without those protections, some insurance companies choose to not stay in a particular market where there appears to be much greater risk.
One thing that's not widely known, is that the Republicans took ACA money budgeted for advertising. It was designed to advertise the benefits of enrolling in plans on the exchanges, primarily to young, healthy people. Participation of young, healthy people in social insurance markets is critical for making them function. But the administration has taken some of that money and they've used it to run ads discouraging people from signing up for insurance and basically denigrating the ACA and saying what a horrible thing it is. That's the most blatant sabotage.
What are the various kinds of models that have been successful globally?
JL: Switzerland, for example, has a health care system that relies on private insurance companies just like ours, except they have some critical differences. One is they must take everybody. Two is they must community rate, which means they can't charge you more if you're sicker or if you belong to a social group that makes you likely to be sicker. Three is they're highly regulated. There are ways of doing a private health insurance system well, but that system has to be a part of a broader environment in which you say fundamentally we are not rationing health care by ability to pay. That's the bottom line.
Do you think there's a chance for a bill that has bipartisan support?
JL: I don't think they're going to be able to do anything at this point. I think Democrats smell blood in the water and they're not going to let anything through. They have absolutely no reason to compromise. The ACA is working sufficiently well that they're not going to be hurting people by leaving it where it is. They're not making peoples' lives actively worse by leaving the ACA in place. If it were damaging to their constituents, they would be willing to compromise, but it's not. By and large, it's benefiting people. Under those circumstances, why would they participate in whatever the Republicans are going to do?
I think many Democrats believe that there are weaknesses and problems with the law that they would really like to see fixed, but there hasn't been anything coming from the Republican side that would do that. And I don't think the Republicans are going to be able to do what they want to do in reconciliation, in part because they can't agree amongst themselves about what they want to do.