Before I get to mental health, which I promise is really coming soon, I’m going to reflect on how the current uproar in Alabama and other states over women’s reproductive rights might call for some careful editing of HR 676, the Expanded and Improved Medicare for All Act. I’ve reviewed the wonderfully long list of covered services previously. Is it clear enough to stop a conservative administration from limiting reproductive care? I fear not—I believe it needs to be substantially strengthened.
Contraception would likely be covered without explicit mention. The bill covers “all medically necessary services”, and preventive care plus prescription drugs are clearly listed. There is no way we are going to list every medically necessary service in the bill itself, but other services that have been historically limited by insurers are mentioned outright, such as dental care and mental health services. To be on the safe side, we should go ahead and specify contraception coverage. Just as for other medications, there would be no co-pay at the point of service—this health plan is pre-paid entirely.
What about abortion? HR 676 needs to specify coverage, very directly. Single-payer advocates sometimes avoid mentioning abortion, even though NOW is a supporter of HR 676. It has been an uphill battle to try and get Medicare for All on the table—I am sure the thought is probably just “don’t go there. Don’t make the job even harder than it is. If it is legal, we can assume it will be ok.” That is likely a mistake.
Maybe one day, contraception will be so excellent and free of side effects that abortion will become obsolete. Maybe one day, an embryo or fetus can be painlessly removed and grown in some high-tech incubator, later to be adopted. Until that time, we must clearly state that we are going to fund a medical procedure the courts have already said is legal.
The best prevention of abortion, a very sad procedure no woman wants to need, is contraception and an educated public. The Dutch have the lowest abortion rates in the world— they got there by teaching everyone how to prevent unplanned pregnancy and making contraception easily available. Sure, contraception isn’t perfect, but it really does help, as opposed to delusional attempts to prevent sex itself. If those who call themselves “pro-life” would quit behaving so irrationally, teens in the US could be just as well-educated, and all women would have access to contraception. Instead, these forces reveal themselves to be about not life but power.
In Alabama, if you’ve read my recent posts, we are being besieged with a flurry of bills written by out-of-state special interest groups trying to keep women from accessing both contraception and abortion. At the same time, the State House may cut funding for a range of services to children, including healthcare, education, enforcement of child support, and foster care. Pregnant women may be unable to get Medicaid if they test positive for drugs, and there are efforts to imprison them as well. It is a truly bizarre double-bind.
Seeing this dismal script played out has made me re-visit the most common critique of single-payer healthcare—that it would be done poorly, because it is government. I have said before that our main protection is the requirement for ALL of us to have the insurance, including legislators and administrators. Will that be enough? Maybe not. As long as there are procedures special to women, we are at risk of male legislators attempting to practice medicine without a license.
In Alabama, we have a chicken farmer—a chicken farmer!—who thinks he knows enough about medicine to tell doctors how to get informed consent for abortion. I will not come to his farm and try to manage his chickens. He needs to stay out of our exam rooms. I mean nothing derogatory about farmers or their chickens. I would say the same about a nuclear physicist. These are just very different specialties.
We already have insurers who get away with poor coverage of women’s health needs. We need to be careful that a national insurance program would not put us at risk for the same problem. How to do it? Perhaps we can strengthen the design of the National Board of Universal Quality and Access. I will go over it again when I get to that section of the bill, but as written it includes a minimum of one health care professional. This board has many tasks, some of which don’t require significant medical training. I believe we need to separate out a Board to include both practicing physicians and patients that will oversee the determination of medical necessity. This board should have a voting majority of physicians and half should be female. Members should be elected by physicians and patient advocacy groups and should not be employed by potentially conflicting interest corporations (like pharmaceutical and device companies). They should also not be government employees.
Our nation’s founders attempted to set a balance of powers in place. I was taught in elementary school this means the legislative, executive and judicial branches. I’m learning there’s a lot more to it! There’s the balance of power between citizens and our elected representatives, between states and the federal government, and between private enterprise and the state. There’s even a balance of power between physicians and patients, one that has evolved markedly for the better in recent decades. Men and women, adults and children, workers and employers—on and on. It’s mindless to argue over big and small government—the argument needs to be around the power balance. Anyone who gets too big, whether that’s government, corporations or a mob, will throw it off.
Power balances can and will get off kilter. Sometimes the problem can be solved by adding a little more weight to one side or the other. Sometimes one of the weights must be removed and replaced. We don’t always know to predict an imbalance until it happens—I doubt if our founders expected Citizens United. Monarchy might have been just fine if it had always been benevolent. If we were a different sort of country, ideologically, we might be ok letting a government board determine our health benefits. I do not trust our current crowd with that job.
Our healthcare balance has been weighted much too heavily in favor of corporate insurers who put their profits ahead of both patients and physicians. We probably can’t fix the problem without replacing them. HR 676 replaces them with government—the other side of the scale needs to be firmly weighted with physicians free to practice quality, professional medicine and patients who demand to be treated with respect, as full participants in their medical care.