Last night’s Democratic debate was a thrilling, no-holds-barred affair that will help burnish the eventual nominee. Despite (or because of) some hard blows given and received, substance intruded. One exchange was especially revealing. John Edwards actually gave the best response, but one that highlights the error in his (and Senator Clinton's) lambasting of the Obama health plan...
The moment came when the candidates were asked a treacherous question: What about those undocumented immigrants? Probably rightly, no candidate proposes to cover those intruders who shingle our roofs and care for our grandparents.
Edwards, however, noted that a strengthened network of safety-net providers would nonetheless be available to provide care. I am not generally an Edwards fan, but he nailed this one.
Yet his answer contradicts a central argument he and Senator Clinton made over the rest of the evening, when they pilloried Barack Obama for failing to be "truly universal"--that is requiring adults to buy health coverage. The truth is that some millions of Americans would remain uncovered under each plan, though each would significantly reduce the number of Americans left without coverage. Even if healthcare reform is passed, serious gaps would remain. Edwards and Clinton are unduly self-righteous when we consider these realities.
Under any proposed reform, some young people will take a bad chance. Others will not be able to purchase coverage. Undocumented immigrants and various severely disadvantaged populations will both face and create additional difficulties and will include many uncovered people. Who will cover the large population of jail and prison inmates, who include a huge fraction of Americans living with HIV, hepatitis C, tuberculosis, and other infectious diseases?
These are complicated problems. Many are not addressed through traditional insurance but through government contracted services, public hospitals and a network of clinics and public health facilities.
These institutions and services have largely gone unnoticed in the health reform debate, they raise a level of complexity that will not fit presidential campaigning. That's unfortunate, because these providers and systems are drowning under the weight of 47 million uninsured people.
They have also faced significant budget cuts during the Bush-43 era. The Bush administration has changed Medicaid and Medicare reimbursement to squeeze safety-net providers. Even as overall medical spending skyrockets, the alphabet soup of public health agencies has faced painful cuts. SAMHSA is responsible to fund many treatment services for individuals with psychiatric or substance use disorders. They have been cut, despite long waiting lists for drug treatment. HRSA finances many services for individuals at the margins of the healthcare system. It has been cut. Even CDC's HIV prevention activities have been cut.
With the exception of CDC, most Americans and most policy wonks couldn't fill out the initials of these agencies, but they are incredibly important.
Even if health reform is passed, our next president must address these matters. An individual mandate will not eliminate the need for safety-net services. Indeed, it may sap political capital needed to gather resources for people we most want to help.
Even if health reform fails, we could move close to universal care by reversing Bush policies and ensuring that people has access to well-funded public services that can provide needed care.