Friday, July 25, 2008

Obama, Healthcare and A Trio of Mythic Figures

(Note: This is my second post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

Barack Obama, the presumed Democratic nominee for President, faces a tough crowd when talking about healthcare in America. As a nurse, I myself am a tough crowd, and my cynicism towards politicians of any stripe runs relatively deep. In my (potentially naive) hopes for a universal, single-payer health plan for all Americans, I see potential for such a future in some of Senator Obama's positions, but when it comes to his chances (and true motivation) to deliver the goods, my jury is still definitively out.

When perusing the Senator's website, we begin with a quote by Mr. Obama from a speech in Iowa City on May 29, 2007:

We now face an opportunity — and an obligation — to turn the page on the failed politics of yesterday's health care debates. My plan begins by covering every American. If you already have health insurance, the only thing that will change for you under this plan is the amount of money you will spend on premiums. That will be less. If you are one of the 45 million Americans who don't have health insurance, you will have it after this plan becomes law. No one will be turned away because of a preexisting condition or illness.”

At face value, this sounds like a wonderful idea and I'm interested to know the details. I heard similar rhetoric from the Clinton Administration in the early 90's (and we all know how that panned out). Still, the sentiment---of universal coverage regardless of pre-existing conditions and no change to current premiums---makes some salient points.

Further on, the data is there for all to see: an estimated 47 million uninsured Americans, including 9 million children. Health insurance premiums have risen four times as fast as wages over the last six years, and less than 4 cents of every healthcare dollar is spent on prevention and public health.

Mr. Obama's plan promises many things:

*Coverage for all Americans that is similar to the coverage now provided to members of Congress

*Guaranteed eligibility

*Comprehensive benefits, including mental health, maternity, and preventive care

*Affordable premiums, co-pays and deductibles

*Subsidies for those who do not qualify for Medicaid or SCHIP but cannot afford premiums

*Simplified paper work and decreased costs

*Easy enrollment

*A National Health Insurance Exchange which provides portability from state to state and job to job without loss of coverage

*Employer contributions with exemptions for small businesses

*Mandatory coverage for children

*Expansion of Medicaid and SCHIP

*Flexibility for states already implementing their own plans

I agree that all of the points outlined above are like music to this nurse's ears. With portability, 100% eligibility for all Americans, expansion of Medicaid---it all seems too good to be true. The site continues to describe plans for lowering costs by modernizing the healthcare delivery system, disease management programs, team management of chronic illness, patient safety, independent research on effectiveness, a comprehensive effort to redress health disparities, and stronger anti-trust laws with a goal of decreased malpractice insurance premiums and fewer lawsuits.

Obama's plan also addresses the need for electronic medical records, less reliance on paper charts, and increased competition for drug companies and insurers, not to mention increased biomedical research, an expansion of the global fight against AIDS, support for Americans with disabilities, mental health parity, lead and mercury poisoning prevention, and increased research related to Autism.

Reading my downloaded copy of the plan in further detail, I was disappointed by the omission of several key issues that have been very much on my mind in recent months:

1) The nursing shortage: although Senator Obama's plan states that the number of "primary care providers and public health practitioners" are dwindling, the plan makes no mention of nurses, the (global) nursing shortage, and the need for massive investment in training, increased nursing faculty, loan programs, and other incentives to a) keep nurses in the workforce, b) prevent burnout by decreasing nurse-patient ratios, c) provide financial incentives for those who wish to be nursing faculty, and d) expand enrollment in nursing education. Where does he stand on the nursing shortage, and how can he not consider it a cornerstone of any meaningful national healthcare policy?

2) Schools and student health: although the Senator's plan addresses the need for expanded physical fitness in schools, improved use of lunch programs, and "more healthful environments" in the nation's schools, the plan fails to mention that although the federal government mandates that there be one school nurse for every 750 children, the national average is more than 1,110 children per nurse, with some states far exceeding even that number. Nurses are essential to the health of our school-age children, and Senator Obama seems to have overlooked this very important point. However, we can rest assured that there is a full-time nurse on staff in any private school attended by Mr. Obama's privileged children.

3) Dental coverage: it is widely understood that dental health is one of the most important forms of preventive healthcare, but the Obama health plan fails to mention dental care in the large or the fine print. Millions of Americans who indeed have health coverage through their employers or a private insurance plan still lack dental coverage for even the most routine care. When it comes to the prevention of infection, improved immune function and proper nutrition, dental care is paramount. Unnecessary tooth and bone loss, oral cancers, and preventable complications from dental diseases are truly public health disasters. If the plan for American universal coverage does not include universal coverage for preventive and corrective dentistry, a serious source of chronic health problems will not have been addressed or alleviated.

4) Stem-cell research: one must take note that the Senator's plan makes no mention of advancing and expanding stem-cell research, a controversial issue stymied by the unscientific and "values-based" prognostications of the Bush Administration, although he does call for increased biomedical research (a euphemism, perhaps, in order to not alienate a certain type of moderate voter?)

I am in no way a policy-oriented person, and when it comes to politics, I tend to sit on the sidelines and watch the wheels turn (with the occasional blog post for good measure). Mr. Obama's healthcare plan is impressive in both depth and breadth, and if he can actualize his plan in the real world, we will certainly be considerably more better off as a nation than we are now. As far as the blind eye that the Senator has turned to the nursing shortage (at least as far as his healthcare plan is concerned), he would do well to realize the importance of nursing to the success of any national healthcare agenda and address the very realistic concerns which nurses have raised again and again.

As I said earlier in this article, my jury is still out vis-a-vis Obama's ability to actually manifest his vision when the campaign is over and the ticker-tape has been swept from the streets. History has illustrated again and again that "politics-as-usual" can rear its ugly head quite quickly when the mad dash of the campaign season is over.

Obama's hardest fight will not even begin until he sits in that famous Oval Office and attempts to wrestle with the troubles of the day. Will his ambitious healthcare plan survive the deluge of responsibilities and decisions (and special interests) which will make themselves painfully known after January 20th? Will he see that nurses really matter, and then succeed in bringing their needs to the table? This (somewhat cynical) nurse isn't so sure, but I am willing to give the Senator the benefit of the doubt as long as his efforts remain focused on the needs of ordinary Americans, and not on the desires of lobbyists, insurance company executives, Big Pharma, hospital CEOs, and others who feel that their agenda should supercede that of the American citizenry.

It is the uninsured, the disabled and the working poor (and their children) who truly carry the burden of our dysfunctional and top-heavy healthcare system. With more money spent per capita on healthcare than any other industrialized country in the world, the United States ranks embarrassingly low in terms of poverty, infant mortality, obesity rates, and many other statistical markers of overall public health. This is a travesty.

Transforming American healthcare is at best a Herculean task of enormous proportions, and any president who shoulders the burden could also be compared to yet another long-suffering mythic figure, Atlas. We can only hope that a President Obama would not instead become a figure more akin to Sisyphus, the mythical man doomed for eternity to roll a boulder up a hill every day, only to have it roll to the bottom before he begins the struggle once more. Mythically speaking, I believe that Sisyphus most accurately (and sadly) represents the life history of healthcare reform in America, with Bill and Hillary playing the parts of the last unlucky Sisyphean figures to traverse that cursed hill.

Obama will struggle against many forces united to defeat a movement towards healthcare parity for all Americans, and the interests with the financial wherewithal to thwart such a struggle are more powerful than most of us know. While my cynicism often gets the best of me, I do indeed hold out hope for a healthcare system that can function smoothly and efficiently, keep costs under control, improve public health, advance research, reverse the nursing shortage, and address the myriad concerns mentioned in this and thousands of other diatribes about the current state of healthcare in these United States.

I wish Mr. Obama Godspeed in attempting what has been up until now an impossible task, and I will continually strive to keep my cynicism at bay as we move closer to the day when a new administration assumes its (Sisyphean?) place in the Oval Office.
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