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by Kent Bottles
The shutdown of the government over the Affordable Care Act made me wonder why Medicaid remains such a divisive issue in American politics. Ever since the opening ceremony of the London 2012 Olympic Games I have been pondering why the healthcare system unites the United Kingdom and divides the United States.
The Olympics media guide in explaining why the British honored the National Health System stated: "The NHS is the institution which more than any other unites our nation. It was founded after World War II on Aneurin Bevan's famous principle, 'No society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.'"
Paul Starr, a Pulitzer Prize-winning professor of sociology and public affairs at Princeton University, addresses why healthcare is viewed so differently in the United States.
"Americans are still at odds over the most basic question about health care: whether it is a requirement for a free life that the community has an obligation to provide or a good that needs to be earned (and if you canâ€™t earn it, too bad for you)," he wrote in "Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform."
Starr traces our dilemma back to the establishment of Medicare as an earned right even though seniors have never paid enough in payroll taxes to cover their insurance costs and Medicaid as an unearned benefit that lacks a moral claim on the community. This history has created a "protected public" who believe they have earned their medical coverage, and they are largely unwilling to subsidize coverage for the less fortunate.
By creating separate health insurance financing for the elderly, the United States created a political problem that has caused partisan bickering. It is noteworthy that the Supreme Court decision upholding most of the Affordable Care Act created a way for governors to elect not to participate in the expansion of the "unearned" benefit of Medicaid.
About half the nationâ€™s governors have declined to support Medicaid expansion. The Alabama Hospital Association recently released a report explaining why it disagreed with the stateâ€™s decision:
Studies in Missouri and Kansas, two other states that have refused to participate in the expansion, found similar positive results.
Lawrence P. Casalino, M.D., PhD, proposed physicians should voluntarily commit to accepting a minimum of 5 percent of Medicaid patients into their practices. Casalino admitted low payment rates, administrative complexity and problems getting specialists to accept referrals make it difficult to include Medicaid patients in a primary care practice. However, "refusing to care for vulnerable, socioeconomically disadvantaged Medicaid patients seems incompatible with" physicians accepting the World Health Organization's Declaration of Geneva (a modified version of the Hippocratic Oath)," he wrote in the New England Journal of Medicine.
The Declaration contains the following pledge: "I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient."
Yestarday Ivan Oransky, M.D., twitted about how the physician recruitment postcard he recently received in the mail boosted "we have NO inpatient responsibilities. Call is by phone only and will be 1 in 6 or less. Payer mix is all PPO, HMO, and Medicare. We have virtually NO Medicaid (less than 3%, if that."
Every other industrialized country has deemed healthcare a basic human right. Until we Americans decide if healthcare is a right or a good that needs to be earned, our healthcare delivery system will continue to divide the nation, threaten to shut the government down and potentially harm the global economy.
Kent Bottles, M.D, is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.
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