By Emily Fisher
This month (October 2013), I had the opportunity to attend the Politics of Health conference and its timing could not have been better. The conference was held during the week that the U.S. government announced a shut down. The shutdown was essentially due to the major disagreements between the two key U.S. political parties, the Democrats and Republicans. And the disagreement was around the budget, but specifically having to do with the Affordable Care Act (which although this is similar to policy that Clinton tried to pass during his time in office, is otherwise known as Obamacare). So, in the United States, we have been experiencing firsthand how the politics around health and health decisions are indeed very divisive and powerful. As Jonathan Metzl in this opening speech stated, “The idea of health as something that transcends politics is quaint”. Instead, health has become “a proxy that pits people against each other.”
Before moving on to particular speaker’s perspectives and illuminating comments, perhaps it would be helpful for me to put this in context. The United States spends an incredible amount of our GDP on healthcare, yet we have an equally incredible amount of burden of illness, especially among our nation’s poor. We also have a substantial amount of people who do not have access to healthcare because they are uninsured. So, although we spend a lot on healthcare, in a vein similar to (although much greater than) other developed nations, our citizens have a disproportionate lack of actual access to it. This is where the Affordable Care Act comes in: expanding the access to health insurance so that those who need health care can pay for it. So, in essence, the idea is that the expanded access to an affordable payment system will increase access to and use of the treatment system.
Jonathan Metzl, Director of the Medicine, Health, and Society program at Vanderbilt, appropriately noted that although health is assumed across the board as a universal good, it is encumbered by ideology and conflict. Therefore, those who have access to it have access by nature of their position of privilege. In a way, that is why the political debate is so essential to changing access to health in this country. There are certain systemic structures in place that actually lessen the chances of good health among certain groups of people. The Affordable Care Act is one way to structurally alter the position of privilege over given to those with financial and other resources. The problem is that this means they will likely pay more in order to even out the balance. Additionally, the government will be paying more. The restructuring involves a sacrifice on the part of those who have in order to compensate for the gross inequalities among those who have not: which many in the United States label as socialism or even communism. So, we see that beneath this conversation are the larger questions about health: “Who has it, who defines it, and [reason #1 for the government shut down] who pays for it?”
In the United States, we see that there are some major factors impacting how these questions are answered. Metzl felt that the dividedness may be a result of one’s political ideology: in focus groups addressing these questions with men, he found that views of health and how health care decisions are made are reflected in people’s lived experiences, specifically tied to their political leanings. Also in the United States is the dichotomy between one’s individual versus their community responsibility. Individualism is highly valued in the U.S. and there is often the assumption that if you simply take care of yourself you won’t have to worry about your health. Therefore, if you are sick, it is likely because you have not been taking care of yourself and it is your responsibility to get better. This is perpetuated through the way we talk about health and getting healthy. For example, we see that within anti-obesity campaigns, the central idea is that typically you can just control your health by exercising and eating right. Health has also become a bodily aesthetic to aspire to and has been highly commercialized. For some this means that health is a moral imperative and for others it is an economic one. In the end, though, however we view health, the United States has “issues and they are growing more deadly and more structural every day” (Emilie Townes).
Following Metzl’s focus on the true reality of politics and health, Emilie Townes, the Dean of Vanderbilt’s Divinity School began to speak. She stated that she wasn’t sure what “political moonshine” congress is making and drinking, but felt that the current “grandstanding is immensely easier than working with pointed and committed diligence to work towards sound public policy.” She argued that we must engage the problem by using a multi-pronged strategy: partnerships must be created from our shared awareness that access to healthcare is a moral quest. There should be a holistic interplay between health and justice, one that fights the various individuals and social forces that block access to health and healthcare. Townes argued that in spite of our need for partnerships, we cannot simply engage in partnerships with those closest to us. This leads us to be too siloed in our work towards justice in health: “When we’re only talking to people who are like us… we are only going to come up with the same strategies.”
Later during the session, an audience question raised the point around economics: “What do you say to someone who says, this is an issue of economics not justice? We need to get our books in order.” Townes felt that that question starts at the wrong place as it ignores the question of what we need to do based on the consequences or our previous actions. However, a panel speaker from the Congressional budget office later reminded us of what the government viewpoint often is and why this is such a complicated problem to address. She pointedly argued that economics is in its own right an important factor because if we are paying so much for healthcare and medicare, then we are not paying for other things also designed to increase the capacity of our people (e.g. education). From her perspective, the government is concerned with focusing on what is being spent on healthcare, especially when it is compared to the rest of the budget and to the rest of the world. She asked us to think about if we are getting the quality of care that we are paying for and to reconsider how money is being spent. “Is health insurance/healthcare the best place for the use of our money?” She pointed out that so far the discussion had largely equated health care and health insurance, which is a mistake. “What are we expanding access to? How are we doing it? How can we address the fact that we may be perpetuating a publically funded system that still gives very unequal benefits across people?”
Townes’ focus on a new beginning point, however, should bring politicians back to the table. When we begin with the consequences of what we do, there is a different path to take. She argued that it is important to look at those people who are not getting insurance in the US, and it is “the poor, the darker-skinned, those who have fewer advocates in positions of power.” Given that consequence, then, what do we do? Townes felt that it may mean that some people do not get what they got before. And although economics plays a role, we need to look at our present results from an economic focus. From her perspective, this then begs the questions: “Who do we think we are as a nation? As citizens? Who do we care about and with and for? Why are we forming ourselves into calloused people? Then rubberstamp that with ‘Its economics, I can’t afford it’. Well some people can’t afford it either and are dying as a result.”
Overall, while the initial speakers helped in framing the problem from a social justice standpoint, the actual steps to take to improve the present situation were less well articulated. Additional panel speakers helped to nuance the present situation by giving a perspective from their respective fields, yet also highlighted the diverse array of perspectives that somehow need to be used to join us together. However, we need to partner in community during this time more than ever. In the words of Townes, “A nation of rampant individualists are bound to fall because we don’t know what makes us, us.”
Further reading suggested by speakers:
Against Health, by Anna Kirkland
Malignant, by Locklann Jain
Smoke, lies, and the Nanny State, by Joe Jackson
Friedman analysis of HR 676: Medicare for All would save billions: http://pnhp.org/blog/2013/07/31/friedman-analysis-of-hr-676-medicare-for-all-would-save-billions/
Published: October 2013, HPC