I stayed up late to watch the Senate make sausage, and vote for cloture at 1am to grease the skids for the health care bill--a leftover piece of business from the New Deal. Not since Lyndon Johnson enrolled Harry Truman as the first Medicare beneficiary in 1965, has there been a more important event for the health of our nation.

If this were the best of all possible worlds--which it isn't--there would be different legislation coming out of Congress. A compromised bill, but a bill, appears close to inevitable. Some staunch advocates for health care reform want to kill this bill, and I respect their sentiments. Howard Dean, former governor of Vermont, former chair of the Democratic National Committee, and former doctor says, "kill the bill." Some abortion rights activists--due to the restrictions on funding for abortion-say, "kill the bill." And all Republicans say, simply because it's a Democratic proposal, "kill the bill."

I was a loyal foot soldier in the radical 1960s when compromise was capitulation, but maybe age brings moderation, or conservatism, and I say pass this flawed piece of legislation.

Bottom line: our health care system is markedly more flawed than either the legislation, or the undemocratic filibuster system that produced it.

We spend more per capita on health care than any other nation and we get worse outcomes. Anyone who fails to see this is on the level of intellectual honesty and/or intellectual ability with a global warming or evolution denier.

The only sense in which we have the best health care system is that we have the best health care system that money can buy--if you have the money to buy it. Foes of health care reform have raised the spurious specter of rationing, but we ration health care by the ability to pay for it. If you don't have the money, you may be one of the 45,000 Americans who die each year from lack of health insurance according a recent study, "Health Insurance and Mortality in US Adults" (Wilper et al. Am J Public Health.2009; 99: 2289-2295). This is a two and a half times higher mortality rate than estimated by a study done by the Institute of Medicine in 2002, which calculated an 18,000 annual mortality rate among the uninsured. Today, uninsured Americans have a 40 percent higher risk of death compared to 25 percent in 1993. These dismal numbers are partly reflective of the fact that there are significantly more uninsured since 2000-47 million today versus 38 million only 8 years ago.

Other public health statistics are similarly grim. According to the CIA World Factbook, U.S. life expectancy at birth ranks 50th. This is behind countries such as Bosnia-Herzegovina, Cyprus, and the Faroe Islands. We rank just ahead of Albania. The much maligned---by conservatives--Canadian health care system is association with a life expectancy of 81, compared to 78 years in the U.S. Critics of the Canadian system point to the long wait times for certain medical procedures, but, not a problem, they have three more years of life to wait.

On infant mortality, according the CIA Factbook, we do rank higher than the countries we lag behind on life expectancy, but this is a bad thing. They all have lower rates of deaths per 1,000 live births than us. Here, in addition to all the other advanced industrial nations, we do worse than Cuba, Slovenia, and Wallis and Fortuna--a small atoll in the South Pacific.

The simple fact is that almost all of the countries that have better health outcomes than we do have some kind of national health insurance. They treat health care as a human right, not a privilege.

And this is not to mention that aside from the uninsured, there are millions more with underinsurance, insurance that will not meet their needs in case of a health catastrophe.

For both the uninsured and the underinsured, for all Americans, inability to afford medical bills is the number one reason for bankruptcy filings.

There is much not to like in the legislation emerging in Washington. There is no public option--let alone a single payer system. Even our pragmatic, compromising president admits that if he were starting from scratch, he would advocate a single-payer system. But we are not starting from scratch.

It is an article of faith among my fellow progressives that single payer is the holy grail of health care reform. It eliminates the profit motive--i.e., insurance companies sucking off money from premiums not to pay for care, but to pay for advertising, marketing, and, most important for them, their stockholders.

A recent study by Sarah Collins and colleagues--"How healthcare reform can lower the costs of insurance administration" (Commonwealth Fund 2009; 1299, 61)--determined that private insurance consumes from 5 to 40 percent of premiums (depending on the size of the group) on profit and overhead, while Medicare consumers only 2 to 5 percent.

Here the U.S. is Number 1 among industrialized nations, spending $156 billion in 2007 on administrative costs and expenses.

I fail to see any value added from an insurance company. As I noted in a previous post, Health Care In Exactly 25 Words, they do little more than manage a transfer of payments from policyholders to health care providers. This is something a computer could do with a well-designed actuarial program.

In other words, for-profit insurance is value subtracted.

But I was awakened from my dogmatic slumber about the single payer system--or completely socialized medicine--when I studied the Swiss system, which is based on private insurance, yet ranks high on public health outcomes, costs, scope of coverage, and universality.

The key is that the Swiss require that basic health care coverage be provided on a non-profit basis. (Insurance companies can make a profit on selling additional policies that go beyond the basic, but munificent, health care package.)

Eliminating the profit motive is the key to having better health outcomes than we do.

I am pained by the many flaws in our legislation. It will not provide universal coverage; millions will remain uninsured. A large chunk of the uninsured will be undocumented residents. They will continue to clog up emergency rooms and receive no preventive care, putting a drag on cost reduction. If you get sick in the UK, they only ask you where it hurts. The proposed legislation will not have a robust public option to compete with private insurance. Neither will there be a Medicare buy-in for people as young as 55. Public monies will not support women's reproductive rights (although men will be able to get Viagra). There will be an individual mandate to purchase insurance with somewhat indeterminate financial support to do so. There will be some reigning in of lifetime caps, but there could be loopholes. There may also be loopholes in the requirement to make coverage available for those with pre-existing conditions. Companies will still be able to age-rate, charging older people more money, rather than requiring everyone to be in the same risk pool. And many of the provisions do not kick-in until 2014.

Overall, many progressive critics view the bill as a gift to the insurance companies. The mandate to buy insurance without a competing public option merely provides them with a pool of new customers.

So there's much not to like, but here are the good parts.

The Congressional Budget Office says the bill will reduce the deficit by $132 billion between 2010 and 2019.

Although 17 million people could remain uncovered, 30 million Americans will gain coverage.

There is a restriction on lifetime caps--even though the bill vaguely bans "unreasonable" caps.

Insurers will be required to pay a fixed percentage of premiums on medical care--85 cents on the dollar for large groups, 80 cents for small groups.

There will be insurance exchanges-marketplaces in which insurance companies will be required to sell to any buyer. Although the exchanges would allow companies to charge an older person three times as much as a younger person, never before has their been this kind of restriction on their pricing powers.

Companies participating in the exchange will have to provide a minimum benefits package.

Although the bill will not have a public option, companies that participate in the exchange will have to provide a non-profit option--a little bit of Swiss cheese.

There will be an expansion in Medicaid-itself a public option, with billions in subsidies to make premiums affordable, and tax credits for families at 400 percent of poverty level--about $88,000 for a family of four.

And, in a little known provision, there will be the CLASS Act-the Community Living Assistance Services and Supports Act--which will be a voluntary long-term insurance plan that would defray part of the cost of nursing home care or home care for the disabled, frail and elderly-an homage to the originator of this idea, Senator Edward Kennedy. (More on CLASS in an upcoming post.)

Do I need to repeat Otto von Bismarck's statement? "Laws are like sausages. It is better not to see them being made," although as I discovered in the wee hours of Sunday morning it is impossible to avert our eyes in these days of instant access via cable TV and the internet.

(Incidentally, Germany, under Bismarck, was the pioneer in social welfare legislation in the 19th century, which included health insurance, worker's compensation, and old-age pensions. During World War I, Germany countered Allied propaganda about the brutality of their troops with posters depicting old, destitute people in England.)

But the most important reason to support the health care legislation is that this train doesn't stop at the station very often. Or to put it another way: health care reform is the football that Lucy has been pulling away from progressive reformers at least since Theodore Roosevelt.

The failure of Clinton health care reform in the early 90s is fresh in my mind. Since that failure, millions more have become uninsured, costs have skyrocketed, and hundreds of thousands have died due to lack of coverage.

I'm not old enough to remember the enactment of Social Security--few are-but I do recall the charge that Medicare is godless socialism, echoes of today's reactionary voices of today. But, today, the elderly are the one group in our society to have virtually 100 percent health insurance coverage. They do not have to worry about how pay their medical bills in times of need.

At the time of its enactment, many felt that Medicare did not go far enough either. But if it had not been enacted, there would have been no foundation upon which to build. The original act, enacted in 1965, did not cover the disabled under 65 (1972), provide Supplementary Security income for the elderly and disabled poor (1972), include hospice benefits (1982), cover federal employees (1983), and, most recently (2003), have a prescription drug benefit.

How many of these enhancements would have been possible if the foundation had not been laid in 1965?

A similar story can be told about Social Security. The original act of 1935 did not include survivor benefits for children or spouses, which was added only four years later. In 1950, the first cost of living provision was added. In 1961, workers were enabled to start receiving benefits (at a reduced rate) starting at age 62 rather than 65. In 1972, a minimum monthly benefit was added.

One of the complaints about the current health care bill is that most of the provisions won't go into effect until 2014, but there are some important provisions that will go into effect immediately. Among them: Insurance companies won't be able to deny coverage for children with pre-existing conditions. You can't be dropped from coverage if you get sick. The donut hole in the prescription drug plan, currently $2,000, will immediately be reduced by $500. Children will be covered under their parents' insurance until they reach age 27.

Social Security's history also demonstrates that changes can be made quite soon after enactment. Under the original 1935 act, monthly payments were not to begin until 1942. Until then, covered workers were to receive a lump sum payment. But new legislation accelerated the beginning of monthly payments to take effect in 1940.

Reactionary opponents of today's bill are gleefully pointing to some surveys indicating a less than majority support for the current health care proposals. Change is uncertain and painful. Better the devil we know, is the prevailing attitude. But although one survey showed support for health care reform dipping to 37 percent, surveys at the time of Medicare enactment showed only 26 per cent approval. Recently, an ABC/Washington Post Poll among Medicare beneficiaries indicated an approval rating of 68 percent, compared to 48 percent approval among private health care beneficiaries.

I am confident that similar numbers will prevail after the passage of the flawed bill in Washington.

If it doesn't pass, it may not be in my lifetime that we see such an opportunity again. When Clinton's health care failed in 1994, I was a youthful 48. Now, 15 years later, I am a youthful 63. Fifteen years from now--if I live that long-I will be a youthful 78. I will have had the benefits of 13 years of socialized medicine, Medicare, while millions more of my fellow citizens will have no insurance at all. Many of them won't have the opportunity to live to 65--and Medicare-let alone 78.

To invoke another often heard cliché: "Let not the perfect be the enemy of the good."

So pass the bill.


My book, Nasty, Brutish, and Long: Adventures in Old Age and the World of Eldercare (Avery/Penguin, 2009) provides a unique, insider's perspective on aging in America. It is an account of my work as a psychologist in nursing homes, the story of caregiving to my frail, elderly parents--all to th accompaniment of ruminations on my own mortality. Thomas Lynch, author of The Undertaking calls it "A book for policy makers, caregivers, the halt and lame, the upright and unemcumbered: anyone who ever intends to get old."

About the Author

Ira Rosofsky, Ph.D.

Ira Rosofsky, Ph.D., is a psychologist in Connecticut who works in eldercare facilities and the author of Nasty, Brutish, and Long: Adventures in Old Age and the World of Eldercare.

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