Affordable Care Act: Closing the gap

We are nearing the end of another summer Ramadan with sixteen hour fasts, record high temperatures, and evening prayers (taraweeh) that finish close to midnight. I’ll be honest; it’s a struggle to remain patient and generous when my sleep-deprived brain is fogged and my calorie-deprived body is exhausted. Yet a hadith tells us that God has no need for us to leave our food and drink if we do not also refrain from uncharitable and unkind words and behavior.

“Many people who fast get nothing from their fast except hunger and thirst, and many people who pray at night get nothing from it except wakefulness.” (Darimi)

Generosity can be a zero sum game. When the mosque runs out of iftar food do I return my box of rice, kabobs and lentils unopened? If I’m running late for prayer, do I give up the choice parking lot space to someone else and find street parking instead? If a woman standing next to me in prayer sways from dizziness, do I hand her my only bottle of water? If she then confesses to me that she’s a diabetic choosing to fast against her physician’s advice (despite an Islamic allowance for not fasting if ill), do I no longer consider her “deserving” of my compassion? What is my obligation to help her and what is her obligation to not unduly burden the community? In other words, to what extent am I responsible for consequences of someone else’s choices?

This concept of who is deserving and who is not comes up frequently in my advocacy work for healthcare reform. We live in a country which accepts responsibility to provide health care for veterans, the elderly, and low-income families. We, as a nation, have agreed that it is our moral duty to guarantee health care to these segments of society via tax-funded, government-administered programs like the Veterans Affairs system, Medicare, Medicaid. The latter two are often referred to as “entitlement programs” – indicating that children, families, and elderly deserve, or are entitled to, support by society.

This system mirrors Islamic values where orphans, widows, the poor and the elderly receive special attention. During the evening prayers in Ramadan, I cannot escape our interconnectedness as a community as we stand shoulder to shoulder, toe to toe. How then can I let my neighbor fall, regardless of her reasons for being ill? I can’t simply step over her to fill the gap she leaves in the prayer row; I have an obligation to help her—she is my sister in faith, my sister in humanity. The same holds true of the accessibility and affordability of healthcare.

Until the passage of the Affordable Care Act (ACA) in 2010, Americans had no system at a national level that addressed the health insurance needs of the general population. The ACA reforms will steadily roll out over four years, but in the meantime most Americans continue to obtain health coverage through an employer (a relic of World War II ear wage controls). Those without employer-sponsored insurance purchase it in the individual market at grossly high rates or pay entirely out of pocket. Our cobbled together system leaves many yawning gaps, with health care expenses contributing to six out of ten personal bankruptcies. Meanwhile, hospitals pass on the costs of unpaid care through pricing.

During one particular ER shift, I saw a child who presented with unexplained fevers, fatigue, and pallor. Blood tests confirmed the diagnosis of leukemia. I thought I had adequately braced myself to break the news to the parents, but I unknowingly delivered a double blow to the father. He told me had recently quit his job to start his own business and had not purchased health insurance. How was he to pay for his child’s cancer care?

On re-telling this story, I have sometimes gotten the response that this father took an ill-advised gamble, and his irresponsible choices leave him undeserving of assistance. After all, this is a country that puts an emphasis on personal accountability and market solutions, not social welfare. This attitude is precisely why repeated attempts to create a national healthcare system have failed in the U.S. It is also why the centerpiece of the ACA is the individual mandate where every individual is considered a default consumer of healthcare and must purchase health insurance. It preserves a marketplace with a choice of health insurance plans but adds additional regulation.

Last month’s Supreme Court ruling supported that interpretation. Obama’s administration argued that since every citizen needs health care at some point in his/her lifetime, the government can require every citizen to purchase health insurance. Those who have health insurance and are satisfied with their coverage can keep it, while those who do not must purchase health insurance or pay a “free rider” penalty. The Supreme Court defined this penalty as a tax that is within the rights of government. Although thinking of my patients as “consumers” and healthcare as a “product” is not how I approach medicine, I support the ACA as an imperfect but pragmatic tool to achieve near-universal health insurance.

But what about those who simply cannot afford to purchase health insurance? The ACA has multiple provisions that are being rolled out over time to assist this portion of the population. For example, ACA promises a tax credit to small business owners who offer healthcare. The ACA also allows young adults to stay on their parents’ health insurance until age twenty-six—a key provision at a time when one in two recent college grads remains unemployed. Under this system, an estimated 30 million people will gain health insurance by 2022. This will still leave roughly 30 million uninsured, but it is a step towards closing the chasm. As a healthcare advocate, I envision a day when our society’s healthcare system, like a prayer row at the mosque, is free of those gaps, and we can stand together as one community. For this to happen, it requires each of us to take responsibility for ourselves, our neighbors, and our society as a whole. In practical terms, who we vote into Congress and into the Oval Office in this election year determines the fate of healthcare reform.
Umbereen S. Nehal, MD, MPH is an academic pediatrician at Boston Children’s Hospital and Instructor at Harvard Medical School. She serves as the co-director for the Massachusetts chapter for Doctors for America, a grassroots organization of 15,000 medical students and physicians advocating an improved healthcare system in the U.S. She is also a member of the Greater Boston Interfaith Organization’s healthcare team which recently celebrated a successful campaign for passage of state-level healthcare payment reform.

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