Someone at the University of Denver has a great sense of humor. As part of the school’s debate event series, there was a showing Monday night of the 1964 comedy, Dr. Strangelove or How I Learned to Stop Worrying and Love the Bomb. In that movie, a farce about nuclear annihilation, the president is an inept politician named Merkin Muffley. When a Soviet ambassador and a general start wrestling, Muffley stops them saying, “Gentlemen, you can’t fight in here! This is the War Room!”
On Wednesday night the war room will be the first presidential debate. And if there were any topic that would cause a real fight to break out, it would be about health care. Fighting over what it takes to make us well? Ah, the logic and the illogic, over the Affordable Care Act is worthy of Strangelove.
Former Massachusetts Governor Mitt Romney created a scheme to make certain that most residents are covered by health insurance. The way he did that was a law that requires every citizen to have health insurance or pay a fine. Six years later Massachusetts residents have the highest number of residents covered, some 98 percent. (The national average is 83.7 percent.)
So when the national health care debate occurred it made sense for President Barack Obama to use the Massachusetts law as a model. It was an idea that had Republican roots, both in Massachusetts and in a 1989 Heritage Foundation report. Romney even articulated the conservative case in a 2008 primary debate. “We said, look, if people can afford to buy it, either buy the insurance or pay your own way. Don’t be free riders and pass on the cost of your health care to everybody else.”
Of course that was before the Tea Party and before the Republican Party shifted to the right. Now the standard rhetoric is about health care as a free market activity with as little government interference as possible. The problem with that ideology is that there is not a single country with such a system. But the United States with its chaotic approach to health care does spend the most of any country on heath care, nearly 16 percent of the entire economy or $6,657 per capita. And gets far less health care in return.
Now, of course, Romney is against Obamacare and the idea of a mandate (except in his home state). In his acceptance speech for the Republican Party nomination, Romney said, “it means that we must rein in the skyrocketing costs of health care by repealing and replacing Obamacare.”
But even that discourse is old. Just last week Romney had a new and different message. He told NBC News: “I got everybody in my state insured. One hundred percent of the kids in our state had health insurance. I don’t think there’s anything that shows more empathy and care about the people of this country than that kind of record.”
Look for this to come up in the debate. Is Romney for repeal or not? And, if so, what would a replacement law look like?
The logic of Strangelove applies to President Obama, too. The Affordable Care Act is an important, nearly impossible, political success. But yet there are still huge problems that remain.
First, if the Affordable Care Act is to work there has to be a better partnership with state (and I would argue, tribal) governments. Much of the expansion, which is supposed to begin in 2014, is through Medicaid. The expansion of Medicaid will be fully paid for by the federal government until 2016 and then decline to about 90 percent. But states are still fighting that expansion and in the Supreme Court’s decision upholding the Affordable Care Act, Chief Justice John Roberts Jr. said that states “must have a genuine choice.”
The second problem for Obama is that the Affordable Care Act doesn’t go far enough in terms of reducing medical costs. A study by the Health Care Cost Institute said health care spending went up 4.6 percent in 2011. This is troubling because health care costs had been declining.
Many critics of the law say the only way to reduce costs is the single payer option, a takeover of health insurance by the government along the lines of the Canadian system.
What’s at stake is that the entire federal budget deficit can be wiped out, if the United States can figure out how to deliver health care at a lower cost. The Affordable Care Act is an early attempt to do that. The debate Wednesday night should be a discussion about that overarching goal. (But don’t expect it.)
Where do American Indians and Alaska Natives fit into that broader health care debate? That’s a future post.
So who has stopped worrying and learned to love the Affordable Care Act?
Mark Trahant is a writer, speaker and Twitter poet. He is a member of the Shoshone-Bannock Tribes and lives in Fort Hall, Idaho. He has been writing about Indian Country for more than three decades. His e-mail is: email@example.com.