In the April 5 edition of The New Yorker, Dr. Atul Gawande, using the passage of Medicare as a model, discusses some of the hurdles that still face the health care reform package that just gained final approval from both Congress and President Obama last week:
On July 30, 1965, President Lyndon Johnson signed Medicare into law. In public memory, what ensued was the smooth establishment of a popular program, but in fact Medicare faced a year of nearly crippling rearguard attacks. The American Medical Association had waged war to try to stop the program, and doctors weren't about to abandon the fight against "socialized medicine" simply because it had passed into law. The Ohio Medical Association, with ten thousand physician members, declared that it would boycott Medicare, and a nationwide movement began. Race proved an even more explosive issue. Many hospitals, especially in the South, were segregated, and the law required them to integrate in order to receive Medicare dollars. Alabama's Governor George Wallace was among those who encouraged resistance; just two months before coverage was to begin, half the hospitals in a dozen Southern states had still refused to meet Medicare certification.
Either boycott could have destroyed the program. Hundreds of thousands of elderly and black patients would have found their hospitals and doctors' offices closed to them. But, as David Blumenthal and James A. Morone recount in "The Heart of Power," their riveting history of health-care politics, Johnson recognized the threat and outmaneuvered his opponents. With the doctors, he cajoled and compromised, giving the A.M.A. a seat on an advisory council that oversaw the rules and regulations, and working with it on a series of thirty "improving" amendments to the legislation. With hospitals, however, the President brooked no compromise. He convened a battle council of top advisers; set Vice-President Hubert Humphrey phoning mayors to pressure resistant hospitals; and deployed hundreds of inspectors to make sure that participating hospitals integrated their wards. There was fury and acrimony. In the final weeks before Medicare's start, though, the hospitals decided to abandon segregation rather than lose federal dollars. Only then was Medicare possible.
The health-reform bill that President Obama signed into law last week--the unmemorably named Patient Protection and Affordable Care Act--could prove as momentous as Medicare. Yet, because most of its provisions phase in more slowly than Medicare did, they are even more vulnerable to attack. The context, of course, is different. As Robert Blendon, of the Harvard School of Public Health, points out, the war against health reform in 2010 has not been an interest-group battle. The A.M.A. endorsed the legislation; hospital associations were supportive. Once the public option was dropped, most insurers favored the bill. The medical world will wage no civil resistance. This time, the threat comes from party politics. Conservatives are casting the November midterm elections as a vote on repealing the health-reform law. If they regain power, they are unlikely to repeal the whole thing. (No one is going to force children with preëxisting conditions back off their parents' health plans.) Instead, they will try to strip out the critical but less straightforwardly appealing elements of reform--the requirement that larger employers provide health benefits and that uncovered individuals buy at least a basic policy; the subsidies to make sure that they can afford those policies; the significant new taxes on household incomes over two hundred and fifty thousand dollars--and thereby gut coverage for the uninsured.
For the full article, click here: Now What? The New Yorker - April 5, 2010
Other articles on health care reform by Dr. Gawande:
Getting There from Here, The New Yorker -January 26, 2009
The Cost Conundrum, The New Yorker - June 1, 2009
