After Obamacare: The New Stakes of US Healthcare Policy
Alondra Nelson is a sociologist and teaches at Columbia University. Her social and historical approach to medicine, science and technology has given rise, in particular, to a book on the health policies implemented by the Black Panthers in the 1960s and 1970s.
Americans of all hues expressed surprise when Barack Obama was elected four years ago (and again last month), with many candidly remarking that they never thought they would live to see the day when the United States would be led by a President of African descent.
As the Obama administration’s policy priorities took shape, many thought it equally unlikely that there would be significant healthcare reform during their lifetimes. Yet the first black US President would once again deliver the unexpected.
When President Obama finally spearheaded the passage of the Patient Protection and Affordable Care Act last summer — after the constitutionality of the law was upheld by the Supreme Court — his team successfully overcame strident partisan resistance from conservatives who had mounted a legal challenge to it. The Obama administration also prevailed against widespread skepticism, not only from the law’s detractors, but also from its supporters. For, very few were confident that a major transformation in American social welfare policy was possible given the failures of several prior presidents in this arena over the last century including, most recently, Bill Clinton, whose frustrated effort at healthcare reform was still fresh in public memory.
Undoubtedly, the new health policy offers crucial and tangible benefits. As the law’s full name makes clear, one of its fundamental accomplishments will be to protect patients from mistreatment by health insurance companies. For example, so-called “Obamacare” guards against arbitrary loss or denial of insurance coverage. The law also mandates that insurance companies use the largest portion of the money they earn toward actual medical benefits for patients, rather than corporate profit. And, thankfully, it is no longer lawful for that the fact of being a woman be deemed an inherent “medical condition” that justifies the imposition of higher fees than what a man pays.
As Obamacare is rolled out, improved access to medical services will be accomplished through a public-private regime that, on the one hand, extends federal healthcare support for the poor and the elderly and, on the other, expands for-profit insurance coverage for some. As a result, the numbers of underinsured and uninsured people in the US is expected to shrink from its current level of 50 million persons to about 20 million. There will be a salient reduction in human need and suffering.
But the arms of Obama’s care wrap around too few. Medical care will remain elusive for those 20 million Americans who do not bear the hardship of acute poverty or inhabit the stable prosperity of the middle class. To fall in the gap between these two circumstances is to face the social purgatory of a healthless, uninsured existence.
As Joan Didion poignantly reminds us in her peerless essay collection The White Album (1979), health insurance is not a cure-all. Didion’s illuminating prose winds its way through the 1960s, pausing along the way to observe some of that era’s most important cultural landmarks. The book’s title essay documents a fraught medical encounter: In October 1967, Black Panther Party co-founder Huey P. Newton was taken to Oakland’s Highland Hospital following an altercation with police that left one officer fatally wounded and another injured. In this same meeting, the black radical suffered a bullet wound to the stomach and a leg injury. As Newton lay bleeding in the emergency room, Corrine Leonard, the nurse on duty that evening had a more pressing matter in mind, his insurance status. She stated,
I heard a moaning and a groaning, and I went over and it was — this Negro fellow was there. He had been shot in the stomach and at the time he didn’t appear in any acute distress… and I asked him… if he belonged to Kaiser [insurance], and he said, “Yes, yes. Get a doctor. Can’t you see I’m bleeding…” And I asked him if he had his Kaiser card and he got upset at this and he said, “Come on, get a doctor over here. I’ve been shot”… I told him we’d have to check to makes sure he was a member.”
Didion confesses to the reader that she too was doubtful of Newton’s status. She initially interpreted this moment as “a classic instance of an historical outsider confronting the established order at its most impenetrable level” until she “learned that Huey Newton was in fact an enrolled member of the Kaiser Foundation Health Plan.” Although he was insured, the activist Newton was not a viable patient or a believable client. He received little sympathy and delayed medical treatment. Then as now, health access was for members only; but membership was no guarantee of compassion.
Compounding this issue of the ethics of diagnosis and treatment is the internalization of a notion of health as a commodity and a mark of morality — rather than as an inalienable right — by those who might most benefit from truly universal health care. Such sentiment reflects the success of an ideological campaign waged by conservatives in the US who coined the term "socialized medicine" and made it the discursive currency of opponents to a public health commons. This outlook is evident comments like this from a single mother as reported recently by The Washington Post: “I feel irresponsible… I feel like I’m less of a person because I don’t even have health insurance.”
These examples are instructive. They caution us that there are matters germane to health equality that cannot be readily legislated. To compel the selling and buying of insurance, as Obamacare does, does not fix the root causes of healthcare scarcity in the US: the broader and widening terrain of socioeconomic inequality and the belief that there are undesirables — not merely those who are uninsurable, but those deemed undeserving of consideration and, therefore, also of benevolence.
In prior centuries, when epidemics cut across all classes of society it was perhaps less difficult to appreciate how healthcare politics implicated us all together. Today, we have storehouses of healthless ones, corralled in prisons, war zones, and refugee camps — set apart. Geographic and social distance makes it harder for us to apprehend our deep corporeal interconnectedness.
The new stakes for healthcare policy in the U.S. are apparent in what Obamacare concretized — the further privatization and stratification of healthcare — and what it left unsaid — the assertion of a right to health. Solutions lie outside of the formal domain of policy and in the realm of ethics and human rights. Yet, it is hard to imagine the application of these remedies at a time when life can be taken with impunity and in a world in which the US kills through drone warfare with each bomb carrying not only the threat of death but also the message that some lives matter less than yours or mine.
Just as it was naïve to believe that the election of the first black president would usher the end of racial inequality — a so-called “post-racial America” — it is equally mistaken to think that the legalization of Obamacare would end healthcare inequality. What healthcare policies can be truly transformative when the very value of life is hierarchical?
Cette ressource a été publiée dans le cadre de la première saison du festival "Mode d'emploi", organisé par la Villa Gillet, qui s'est déroulé en novembre et décembre 2012.
Pour citer cette ressource :
Alondra Nelson, "After Obamacare: The New Stakes of US Healthcare Policy", La Clé des Langues [en ligne], Lyon, ENS de LYON/DGESCO (ISSN 2107-7029), février 2013. Consulté le 04/12/2023. URL: https://cle.ens-lyon.fr/anglais/civilisation/domaine-americain/la-presidence-americaine/after-obamacare-the-new-stakes-of-us-healthcare-policy