In Hemingway’s The Old Man and the Sea, as Santiago‘s tiny boat is being dragged out to sea, he promises to say ten Our Fathers and ten Hail Marys and to make a pilgrimage to the Virgin of Cobre if he catches the marlin. And, of course, there are the proverbial bargains offered from foxholes — If I get out of here alive, I will ……
We are in a small boat headed out into uncharted and terrifying water. Or maybe we are in a foxhole. I expect that, like Santiago, many of us are making promises, including many who previously haven’t cared about vast disparities in health and income in our country. We are being forced to see that all of us are in this together.
Not only are the privileged not immune from COVID-19, but their health is entwined with the health of everyone else in the country. All of us are more vulnerable because of the staggering number of people who can’t even afford to find out whether they have the virus, let alone afford the cost of treatment, or the loss of wages from staying home. We are confronting the reality that not just our health, but our whole economy, our comfortable lives, can be brought low because of our inter-connected health.
So right now, we are committed to fixing these problems. If we live through this, we promise to do something to make our health system more equitable. We promise to ensure that low-income people, the people living paycheck to paycheck or unable to work, have adequate health care, have paid sick leave, don’t have to choose between going to the doctor or feeding their families. We will start addressing the disparities we are being forced to see.
Will we do it? When we are finally on the other side of the coronavirus pandemic, will those of us who survive make good on our promise? Maybe. It depends on how much we let ourselves learn. A recent New York Times article offered some brutal statistics about the state of our collective health: Low-income people are 10 times likelier than people with financial means to have chronic health conditions. Underlying chronic conditions can make the virus up to 10 times more deadly. People infected with the virus still have to work because, while 90 percent of people in the top income quartile have paid sick leave, only 47 percent in the bottom quartile do. Last year, 26 percent of Americans reported that they deferred health care or didn’t fill prescriptions because they couldn’t afford it.
We are starting to see states scramble to get and keep their inhabitants enrolled in Medicaid and in health insurance plans offered through the Affordable Care Act. “Obamacare” is not such a dirty word right now. Members of Congress, who previously vowed to gut Medicaid, can now thank whoever they thank that they didn’t succeed. Medicaid is proving to be the resilient, flexible source of health insurance that we need in a crisis. The Medicaid program is designed so that when the need is greater, federal funds increase. Everyone eligible gets covered. That would not be the case if Congress had passed a bill turning Medicaid into a “block grant” in 2017 or if the current administration succeeded in doing the same thing without congressional action, as they proposed this January (just days after the first confirmed coronavirus cases in the U.S.).
At the National Health Law Program, we are busy helping states take advantage of the flexibility Medicaid offers in this emergency. Medicaid has built-in flexibility that is intended to help get and keep more people covered, allow payment for services offered in novel ways, make it easier to get prescription drugs, and facilitate greater access to telemedicine. We are also advocating, as we always do, on behalf of people and services that get shortchanged—people with disabilities who need assistance to stay in their homes, people who need reproductive health services including abortion care, people who require substance use treatment, and those who rely on mental and behavioral health services.
When this is over, what will we have learned? What should we have learned? For starters, we should take a collective vow that health care will no longer be a political football. Republican governors will not turn down health insurance for 2.3 million uninsured residents because accepting Medicaid expansion may hurt their chances of being reelected. Assuming that the Supreme Court rejects the current challenge to the constitutionality of the Affordable Care Act, we will stop bringing baseless legal challenges to the statute and, instead, put our energy into making it more durable and more effective. Instead of trying to gut Medicaid funding, we will ensure that funding for Medicaid is as necessary as our national security funding. Because we now understand that it is.
Health care requires our collective national attention. When we make it to the other side, let’s analyze what worked well in the crisis and what we can improve. How do we get everyone insured? Whether we create a new program that provides health care for all or we keep building on and enhancing Medicaid, CHIP, the ACA, and Medicare, we will need to ensure that low-income people don’t keep losing out. Medicaid has essential protections for low-income people. Among these protections are robust services for children and people with disabilities, transportation assistance to help get people to their doctor, due process rights that allow those with little power or clout to challenge a big company’s denial of the health care services they need. Those protections need to remain in whatever health care program emerges on the other side of the coronavirus.
Once we stop trying to cut back on health care, we can start tackling the big problems. If we remember the coronavirus lesson – that all of us are in this together, maybe we will have the will to do something about the other big determinants of health – income inequality, housing insecurity, racism and bigotry, unequal education opportunities. Over the centuries, these ills have been deeply embedded into the fabric of our country, and it will take collective will to change them. From our shelters-in-place, as we read ever more dire projections about which of us may die, we are committed to doing better.
We see how connected we are.
Will we do this when we are on the other side of the coronavirus? Maybe. If we remember.