We seem to live in an era in which, unless an event is utterly political or blatantly immoral, it seldom causes a ripple. The ruling by the supreme court of the United States of America delivered on June 28 is one of the most fundamental social legislations of our times, with elements of a political thriller. But it has perhaps gone largely unnoticed in the Indian press.
The US has no dearth of wealth and opportunities of wealth creation. But it had a fundamental weakness in its healthcare system. More than 30 million Americans are without any form of health insurance. Those who can afford it, have to pay exorbitant premiums to secure comprehensive healthcare. Insurance companies are extremely reluctant to insure the elderly and those with pre-existing conditions. So the older and sicker you get, the more vulnerable you become. The uninsured took a huge risk of making do without the assurance of a regular healthcare. When they were in any kind of medical emergency, the cost of treatment was passed on to the Medicaid system, which was proving to be a huge burden on the State economy. The elderly and those with health problems suffered a similar plight.
This was not all. The cost structure was very different in the case of state hospitals and of private clinics and trust institutions. The private facilities would hugely inflate the cost of treatment in order to sustain the high cost of medicines and manpower. There was virtually no system of general practitioners making the initial diagnosis and then referring patients to specialists. Americans have the habit of approaching specialists first, and this again leads to unwanted investigations and huge bills. So it was proving to be impossible to break the cycle of high costs and higher premiums together with inadequate population coverage.
It is in this context that we need to appreciate the courage and conviction of Barack Obama. Although his hands were full — with a struggling economy, increasing unemployment, the threat of terrorism and challenge of re-election — he chose to face the social challenge head on. The Affordable Care Act was drafted and it generated the most vicious debate the US has witnessed in the last few decades. What did Obama set out to achieve?
Every US citizen was being implored, rather compelled, to have a health insurance. If they did not, the State had the option of imposing a fiscal penalty. Insurance companies had to insure the elderly and those with medical conditions. The premium rates of various companies will be floated in an exchange market, giving the people an opportunity to make their choice. The system is set to change, with more emphasis on general practitioners and primary care. Galloping costs of treatment and investigations are to be brought under the scanner and rationalized. There are more provisions in the ACA, but perhaps this is the core of the reforms that Obama has bet his political career on.
This sounds great. Where is the contradiction? America has a phobia of left of centre socialism and tends to confuse it not infrequently with communism. So the extreme Right, which is still hypnotized with a ‘grab the opportunity and grab the dollar’ kind of morality, has no time to think of the less privileged. Cost is justified by the Right-wing lobby if one can afford to pay.
Profiteering out of healthcare so far has not been a taboo. So the extreme commodification of healthcare at the expense of society has been discussed over the years but nothing has been done about it. The first coloured president upset the status quo by making it his primary agenda.
All the measures will, at some stage, result in a small but unavoidable rise in taxation. This is in order to enable the State Medicaid system to expand. This is a taboo to the American mindset. Citizens of a liberal economy would give a hand and a foot but avoid paying a cent extra in taxes, no matter what they are for. That is perhaps the stiffest challenge in the way of implementing the healthcare act — to make the tax-paying Americans pay a bit extra to make comprehensive healthcare possible. In the week when the debate and drama were at their crescendo, I happened to be in the US and listening to popular opinion by chatting with cabbies and concierges. Their opinion was most interesting — ‘the reforms sound good as long as the taxes do not go up.’ Sorry folks, if Obama has his way, they will, but for a worthy cause.
The legal and political angles to this thriller were no less absorbing.
Obama had truly caught the Opposition on the wrong foot. Many of the Republican states, notably Massachusetts under Mitt Romney, had implemented quite the same provisions at the state level but kept opposing Obama on the national platform. Even hardcore Republicans find it hard to challenge the social implications of “Obamacare”. That was a great political move — to have waited when the Opposition had tacitly endorsed the measures.
The last hurdle was perhaps the nail biter as it was being presented to the supreme court for constitutional validation. Was it in the power of the president to impose mandatory healthcare cover for all its citizens and also fundamentally alter the nature of the healthcare and insurance industry? There was grave doubt in legal circles over whether the supreme court would concur, especially under a chief justice with a strong conservative trait.
On the morning of June 28 — as most in the Obama team were chewing their nails off — the first words from the supreme court were that the president had lost the case — end of a dream? Luckily, it was a media blunder. The supreme court, in a split decision, had upheld the act as being constitutional. John Roberts, the chief justice, contrary to all expectations, cast his vote in favour of what is deemed to be one of the most far-reaching acts of social legislation since the formation of the National Health Service in the United Kingdom in 1948. For some of us, who are embedded in healthcare activities, the medical reforms of the US are like a life-saving dose of oxygen, especially since there is criminal indifference to issues of healthcare and social development all over the world.
These days, when India and the US are perhaps warming up to each other, we have lessons to learn from the courage of one who is not merely a political leader but also a visionary. Perhaps the unending dialogues on outsourcing and nuclear deals can be substantiated with exchanges of knowhow on health economics and medical insurance.
President Obama — best of luck, there is a long road ahead. But do whisper some of your ideas in our leaders’ ears when you see them next.