Allan Wilke's Forum, Second Stage: A Few Words In Defense of Health Care Insurance Reform

Last Updated on April 16, 2022 by Lee Burnett, DO, FAAFP

Allan Wilke, MD, Ross University School of Medicine

I’m writing this the weekend after the conclusion of the United States Supreme Court’s 3-part miniseries, Obamacare – Threat or Menace. It comes 27 months after I was persuaded to write a commentary on health care reform for the website, and my omelet-making versus refrigerator-raiding-for-leftovers analogy was foisted upon an unsuspecting public: [See Forum on Health Care Reform: Doctor Allan Wilke’s Thoughts].

Now a follow-up commentary has been requested. Folks should be careful what they wish for. Against my better judgment, I foist this.

A lot has happened since December 2008: Ted Kennedy died, a Democratic-controlled legislature passed and President Barack Obama signed the Patient Protection and Affordable Care Act (ACA or PPACA), the Tea Party rose to prominence and put the Republicans back into control of the House of Representatives, the Arab Spring blossomed, Michael Jackson and Whitney Houston died, and Adele swept the Grammy’s. What does it all mean?

The late Senator Edward Kennedy (left) at the signing of a bill by President Barack Obama (right)

Even the fevered imagination of Aaron Sorkin could not have come up with a West Wing scenario like this one. In May 2008, a full 6 months before Obama’s electoral landslide, Kennedy, the larger-than-life champion of universal health care picked the wrong time to develop a brain tumor and left the Senate floor for extended periods of time, returning on a stretcher on occasion to cast key votes. Obama, exploiting social media, went on to victory in November, pledging hope and change, and got the gift of expanded majorities in the House and Senate.

We naively saw passage of health care reform as a slam dunk. A Democratic President (and point guard) and the Democratic congressional majorities were set to make our hoped-for health care change a reality. It was a shock, then, but maybe not all that surprising (these are Democrats, after all), when we witnessed the legislative process begin to unravel. Kennedy’s negotiating skills and his sincere friendships with his colleagues across the aisle were sorely missed, and an opportunity for a bill with limited bipartisan support slipped away.

Scott Brown (left), the newly elected junior senator from Massachusetts, shares the front seat of his pickup truck with Worcester radio personality Bob Oakes

Senator Kennedy picked the wrong time to die, too. Massachusetts elected Scott Brown (a Republican!) to replace him. Could the apocalypse be upon us?

The filibuster-proof Democratic majority in the Senate evaporated. In the end Obama, Speaker of the House Nancy Pelosi, and Senate Majority Leader Harry Reid raided the ‘fridge and cobbled together a collection of health care reform proposals, including the individual mandate, originally advocated by conservative Republicans and Bush I in 1989.

(Note: If I had been in charge, I would have thrown the Republicans a bone and included tort reform. Unfortunately, trial lawyers hold too great a sway over the Democratic establishment for that to happen, and nobody asked me.)

The Trinity snatched victory from the mouth of defeat in a ham-handed manner that involved an arcane legislative rule. This tactic, however, angered the populace. Exploiting social media, the Tea Party took off and was instrumental in returning Congress to Republican control and reducing the Democratic majority in the Senate to gridlock level.

Meanwhile, events in the rest of the world were not put on hold. The most dramatic were the emergence of grassroots democracy movements in the Arab world and the Japanese tsunami. Ordinary citizens, exploiting social media (and, eventually, military-grade hardware) managed to bring down the governments of Tunisia, Egypt, Yemen, and Libya. Syria is next. I hope.

A magnitude 9.0 earthquake off the Pacific coast of Tohoku triggered a giant tidal wave, which managed to take out a nuclear reactor at Fukushima that had been built to withstand an earthquake and maybe a giant tidal wave, but not both. Where is Godzilla (or God) when you really need Him? Ghost ships ride the waves, threatening to run ashore in Alaska. Sarah can wave to them from her back porch.

I can hear Jurassic Park’s Dr. Ian Malcolm lecturing about chaos theory. People died. Babies were born. Life finds a way.

In June 2009, Michael Jackson, the king of pop, died of a propofol overdose, ostensibly because he wanted a good night’s sleep. He was 50 years old. His personal physician, a cardiologist, was eventually convicted of involuntary manslaughter. I don’t know if Mr. Jackson had a heart problem, but his head was definitely not screwed on right. Neither was his cardiologist’s.

In February of this year Whitney Houston, another massively talented artist, died in her bathtub at the tender age of 48. The cause of death was drowning after ingestion of several psychoactive substances. And maybe heart disease.

Three days later on the strength of her second album 21, Adele Laurie Blue Adkins, a British blue-eyed soul-singer, won six of six Grammy awards, steamrolling her competition, including Lady Gaga. (Note: I really don’t know what color Adele’s eyes are, but, if they aren’t blue, they should be.)

A portrait of the artist from Adele's website

Adele’s former boyfriend has sued her, claiming he inspired the heartache of her album and is entitled to a share of her success. He’s probably heartless; he certainly suffers from testiculomegaly.  At the same ceremony, Diana Ross (but not the Supremes) accepted a lifetime achievement award. Aside from anorexia, I am not familiar with her health history, but as Herbert observed, “Living well is the best revenge.”

The ACA was designed to reform US health care slowly, in bits and pieces. The most polarizing part, the individual mandate, which will require almost every US citizen not already receiving health care benefits to purchase insurance or pay a fine, won’t come into play until 2014. The more popular parts (allowing young adults to stay on their parents’ policies until age 26, preventing insurance companies from denying coverage to people with pre-existing conditions or terminating coverage for people who become sick) are already in force. Rumor has it the ACA was born this way to promote Obama’s re-election.

Late in March 2012, the United States Supreme Court heard six hours of oral arguments in challenges to the ACA. This represents the longest oral arguments on any case in the last 45 years. (Note: the case in 1967 that was longer concerned natural gas rates in western Texas and southeastern New Mexico. If hot air can be equated with natural gas, I think I see a pattern here.)

The first day the justices heard arguments about whether they should even be taking up the case. I heard a collective, “Hell, yes!” Day 2 was devoted to the constitutionality of forcing someone to buy health insurance or broccoli.

Supreme Court Justice Anthony Kennedy, whose thoughts on PPACA interest many people, speaks at his alma mater, Stanford University

The last day looked at whether the federal government could legally arm-twist the states to expand Medicaid and whether the US had to eat all the leftovers or could the individual mandate be tossed in the garbage separately. The results of these high-level deliberations won’t be revealed until June.

I don’t pretend to know how the Supremes will decide the case, but I’ll bet you a Romney-sized wager, it will be 5-4. I’m not sanguine. This group is not going to win a lifetime achievement award. The words that Randy Newman sang in his 2008 composition, A Few Words in Defense of Our Country, [cf.] keep rattling through my brain. Well, (to quote Mr Newman), Pluto’s not a planet anymore either!

The fact that this is playing out in the foreground of Obama’s reelection campaign is extraordinary, but not unprecedented given the Court’s apparent interest in dabbling in election politics (i.e., Bush v. Gore). Obama’s presumed opponent will be Mitt Romney, former governor of Massachusetts, who in 2006 enacted similar health care reform legislation there (the Massachusetts Health Care Reform Plan).

Obama says he patterned the ACA after Romney’s law, but Romney is stridently disavowing ever having any relations with that law. Baby, baby, where did our love go?

As the provisions of the law have been phased in, cracks in Massachusetts’ primary care infrastructure have emerged: there are not enough family docs to take care of Massachusettsans. Who would have guessed? Even so, the law has polled favorably with patients and physicians alike.

In the meantime, other state governments and health care systems are moving full steam ahead, preparing for reform measures yet to be in force, especially the establishment of insurance exchanges and accountable care organizations. Vermont passed a universal health care law. I take that to mean that Vermonters can get health care anywhere in the universe. If the ACA is struck down, do you think these efforts will be reversed? Me neither.

British Prime Minister Winston Churchill

Winston Churchill once remarked, “The Americans will always do the right thing… after they’ve exhausted all the alternatives.” I think this is how we’ll finally get health care reform: some parts will be legislated, some will be entrepreneurial opportunities, some will be the children of necessity, and others will be the children of CYA (“cover your assets”).

So, how do I make sense of all of this? What lessons do I take?

1. When you are trying to promote a project or program, it doesn’t matter how powerful your position is. Get everyone involved: everyone has a stake, everyone benefits, everyone shares responsibility or blame.

2. You cannot ignore people-power or the power of social media. As much as we’re led to believe otherwise, people are not sheep. If you provoke or oppress them, eventually they will rise up. Be on the right side of history. Especially, if they possess military-grade hardware.

3. There are not enough primary care physicians, but, for God’s sake, don’t allow a cardiologist to become yours.

4. Talent is wonderful, but it doesn’t immunize you from life’s travails. If you can transform life’s travails into art and real money, more power to you.

5. Death, despite all our protestations to the contrary, is not optional. It can come early, it can come late, but it will come. And you can count on it to disrupt things.

6. Planning is wise, but hubris isn’t; you can’t plan for every contingency, because you don’t know them all. T. rex will escape the inescapable confinement. Pride goeth before the fall.

7. You can’t hurry love. Or health care reform. There will be disruptions. Deal with it. Health care reform will come to the US, because it has to. After we’ve exhausted all the alternatives. Unless the Mayans were right.

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Joey Schumpeter

Joey Schumpeter

A Few Words in Defense of America’s System of Checks and Balances

I am pleased to see Dr Wilke’s forum return in its second stage. He is obviously passionate in his desire to extend the benefits of health insurance to the widest numbers of Americans as possible and expresses his belief that ACA is the vehicle that will accomplish that goal. Thus, his instincts are to defend the act and excoriate those who would starve it of funds or find its key provisions unconstitutional.

At the same time, however, in his facile and amusing journey through the pop cultural and political environments in which ACA is to be implemented, Dr Wilke has either inadvertently or deliberately identified some of the squirming flies in the ACA ointment.

Although he professes to believe in Churchill’s pronouncement that Americans, after exhausting all other possibilities, will eventually choose the right course of action – in itself a bit of a tautology, since the right course of action is being defined by whomever has chosen to employ the Churchillian epigram (Supreme Court Justice Antonin Scalia and Congressman Ron Paul might have something quite different in mind from Dr Wilke) – he reveals his fascination with Professor Ian Malcolm’s explanation of the “butterfly effect” to the distinguished tourists to Jurassic Park.

If one cannot predict the ultimate consequences of a tiny butterfly flapping its wings in China, what about the “cobbling together” of a massive piece of legislation that affects virtually all of the American population, that almost surely will have unintended consequences for both the nation and each individual American?

In reflecting on the events since Dr Wilke’s original 2008 forum piece, I concede that the unexpected political (Arab Spring and Tea Party) and tectonic forces (Fukushima) that engulfed us are worthy of note, but I think there are other forces at work that may decide the fate of the ACA.

Despite the impression of unrelieved gridlock, there is an example during this period of the two parties, led by the coordinated policies of the successive G. W. Bush and Obama administrations, that resulted in massive restructuring of the housing and banking sectors – the Federal Reserve’s response to the simultaneous collapse of Lehman Brothers, Bear Stearns, Washington Mutual, Countrywide, etc.

Here the political leadership of both parties cooperated. The results were breathtaking and transformative. It’s my personal belief that it has been all to the good.

But there was collateral damage far beyond the Detroit and Vegas neighborhoods of multiple foreclosures. The idea of massive federal intervention in the economy in the one sector has generated a massive counter-reaction. The reaction is clearly at the heart of the Tea Party’s founding and has some resonance in the Occupy movements as well.

Then, as the idea of direct action against an out of control government came to be fashionable through social media and candidates willing to articulate the messages and contributors with big bucks to diffuse them, there emerged the disorderly spectre of a profligate Greece, with the seeming capacity to destroy all of Western Europe.

For the first time in my memory, a sizable portion of the American electorate seems predisposed to taking account of what things cost and of worrying whether there is enough money, even if every tax that can be conceived were passed, to pay for all the commitments made so far.

The French philosophe Montesquieu and the American patriots who incorporated his ideas into our constitution created multiple checks and balances to frustrate the totalitarian approaches to governance. It seems messy, and as Dr Wilke points out, it could well prevent some good ideas (and some bad ideas) from being implemented quickly, but, given the choice of living in Syria, Greece or the United States, I plan to stay where I am.

Allan Wilke

Allan Wilke

Thank you to Joey Schumpeter for his remarks. It was almost as much fun to read them as it was to write my commentary (“There’s nothing to writing. All you do is sit down at a typewriter and open a vein.” -Red Smith or Paul Gallico, take your pick.) Seriously, Schumpeter make several insightful points and adds to the complexity of this subject.

I want to clarify three points: I am not so much a fan of the ACA as I am a believer that it is better than what we had before. My personal preference actually runs more along the lines of Medicare-for-all. And if I identified any flies in the ointment, it was definitely advertent. Finally, as much as I am fascinated with Ian Malcolm and chaos theory, it’s that other Ian, Ian Shoales, who has had a greater influence on my world view.

Can’t wait to do this again in three years.

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