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January 1 2014: US health reform's Gettysburg moment

Posted by John McDonough  December 29, 2013 07:58 PM

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Going out on a provocative metaphorical limb here, I'll enjoy hearing the sound of the saws.

A compelling comparison can be made between where the US is at right now on health reform and the nation's fortunes 150 years ago, right after the Union Army's victory at Gettysburg on July 4 1863.

Before that, let's consider January 1 2014. In the midst of constant turmoil over websites, gettysburg-confederates.jpgenrollment snafus, policy cancellations, political attack ads, and more, we are missing something important. January 1 2014 may well be the most transformational day in the history of United States health care policy, ever, and nobody seems to notice. What's so big about 1/1/2014?

First, this is the first day of fundamental reform of the business and regulation of health insurance in all 50 states:

  • Banning the practice of "medical underwriting" by which insurance companies rate enrollees based on their health status and medical history,
  • Banning pre-existing condition exclusions from US health insurance everywhere,
  • Establishing "guaranteed issue" as the new operating paradigm for individual health insurance,
  • Completely eliminating lifetime limits on all health insurance, and
  • Establishing "minimum essential benefits" that must be included in nearly all licensed health insurance policies everywhere.

Second, Medicaid coverage begins for close to five million uninsured low-income Americans in participating states, with many more millions to follow. This will happen more slowly than the Affordable Care Act's designers expected because of the Supreme Court ruling that made the Medicaid expansions optional for states. But come they will.

Third, private health insurance coverage starts for about one million Americans purchasing coverage through the federal/state health insurance marketplaces with many more to follow.

Fourth, the principle of personal responsibility -- aka the "individual mandate" -- to obtain health insurance coverage takes effect, with the Supreme Court's stamp of approval.

Lay aside for the moment whether you think these changes are celebratory or catastrophic, and just consider the momentous nature of the changes taking effect on this coming Wednesday. What historical date in U.S. health policy history might rival this one? The only one that comes to my mind is July 1 1966 when Medicare coverage took effect for the first cohort of senior citizen enrollees. No doubt that was historic, though I would argue that the scope and breadth of changes coming this week are far more consequential by comparison.

And the consequence of the changes coming on New Year's Day helps explain the harsh intensity of the ACA's opposition over the past four months. Because -- as Wisconsin Republican Senator Ron Johnson explained, as reported in the New York Times last week -- after Wednesday, coverage is no longer hypothetical, it's real. The effects of repeal and defunding are no longer fantasy, but actions with life-threatening consequences for real Americans, millions of them. 

“It’s no longer just a piece of paper that you can repeal and it goes away,” said Senator Ron Johnson, Republican of Wisconsin and a Tea Party favorite. “There’s something there. We have to recognize that reality. We have to deal with the people that are currently covered under Obamacare.”

Since the ACA's signing on March 23, 2010, there have been many consequential battles over the health reform law, though none as vital to its foes than preventing 1/1/2014 from happening. The ACA's opponents seem to understand Wednesday's significance far more cogently than do the law's supporters.

I analogize the Republican shutdown of the federal government this past October as that Party's "Pickett's Charge," the final and failed Confederate assault at Gettysburg before their ignominious retreat. Gettysburg did not end the Civil War which had another 21 months to go, though it did signal the final result. After Gettysburg, there was no more chance of European support for the Confederacy, no more military offensives, just a slow and vicious endgame.

Likewise, getting to 1/1/2014 is not the end of the health reform war. Make no mistake, ACA's defenders have been battered, wounded, and bruised throughout the fall campaign, with many self-inflicted wounds, notably the catastrophe, one for the history books for sure. And there will be fierce skirmishes ahead -- particularly the battle for control of the U.S. Senate this coming fall.

But as of Wednesday, as Senator Johnson recognizes, millions of formerly uninsured Americans have real coverage, and there will be no taking that away from them, any more than there was the possibility of re-enslaving freed African Americans after 1863.

I can hear the criticism -- how dare he compare the Civil War which cost an estimated 750,000 American lives with the political fight over Obamacare? Here's how. The Institute of Medicine, in its landmark study of uninsurance in America, estimated in 2002 that approximately 18,000 Americans die every year because they lack health insurance, with many thousands more suffering needless injury and harm.  Other estimates suggest as many as 45,000 lives lost per year because of uninsurance. 

Yes, there are more fights over the ACA ahead. But the overriding importance of 1/1/2014 is the actualization of a new principle of health justice for all Americans, however flawed that principle is in form and in practice under the ACA. That principle now is here to stay.

Just like the fight against slavery did not start in 1861, the fight for health justice for Americans did not begin in 2009. Both involved centuries and decades of struggle and turmoil. The end of the pitched battles of the Civil War by no means ended the need for constant vigilance and action. 2014 is no more the end of the struggle for health justice than 1865 was for justice for African Americans. Still, 1/1/2014 is a landmark day worth noting and celebrating, especially for those working tirelessly every day all across the nation, in red states and blue, to fulfill its promise.

Congressman Jim Clyburn (D-SC) presciently called the ACA "the civil rights act of the 21st century." Unlike the Civil War, we don't wage the health reform conflict with guns and cannons; unlike the fights over Civil Rights in the 1950s and 1960s, we don't wage this conflict with attack dogs and water cannons. Still, this health reform struggle is no less a battle or a conflict, even as we wage it, thankfully, without violence. We wage this battle through politics. My favorite definition of politics: politics is the way people decide who gets what -- without resorting to violence.

We should be thankful we can have this level of conflict in American society over fundamental values, and avoid killing or injuring each other. We also should recognize that, even though we are not physically harming each other, we are competing over what kind of a society we want to be.

Lots and lots of hard work still ahead. After Wednesday, the ultimate outcome is no longer in doubt.

So let me offer everyone a very happy new year!

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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