Article — From the February 2009 issue

Sick in the Head

Why America won’t get the health-care system it needs

the government sector

When Congress is in session, Michigan Congressman John Conyers holds a regular public meeting at the Rayburn House Office Building, where, if you happen to be interested in health policy, you are welcome to join like-minded citizens in considering the merits of HR 676, also known as The National Health Insurance Bill. If signed into law, HR 676 would require a single payer (the government) to provide health insurance to every American, which is likely why most Americans have never heard of it. Nearly every other wealthy nation has a single-payer system, but in the United States—or at least in Congress—single payer generally is understood to be too utopian, too extreme, and certainly too socialist for domestic consumption.

I was surprised, therefore, when I went to one of the meetings in July and found a hundred or so people stuffed into a stately conference room. Everyone had a notebook, but no one had the bored look of a political reporter. These were activists, young and mostly black or Hispanic. Conyers, along with several guest speakers, sat behind balusters on a low platform that crossed the width of the room. At the other end, near the door, someone had arranged a banquet table potluck style, with tins of homemade brownies and cupcakes. I pushed my way to one of the few remaining chairs in the back as Conyers, now at the lectern and speaking softly into a microphone, asked whether anyone would like to address the gathering.

The first to speak was a large man in an immaculate green suit. “My name is Kenny Barnes,” he said in a raspy whisper, “and I’ve got an organization called ROOT, Reaching Out to Others Together. It deals with the—my son was murdered, by the way—and it deals with the epidemic of gun violence that’s taking place in the United States of America.” Barnes quickly explained this striking interjection. Children in Washington were being traumatized by a culture of gun violence, and they had little access to mental-health services. A lot of them were being labeled as learning-disabled when in fact what they probably had was post-traumatic stress disorder. They needed help and they weren’t getting it.

Conyers thanked Barnes, and then more people spoke. Each of them told a similarly compelling story. A group of people had been forgotten; they needed help and they weren’t getting it. Some of the groups fit within familiar bounds—minorities with AIDS, for example—but others were parsed to an almost surreal degree of precision. One woman spoke, persuasively, about the special problem of black men who don’t floss. Another addressed the challenge stoplights present to old people who cannot walk across the street in the amount of time it takes for a green light to turn red. Conyers’s aides, watching from seats next to the lectern, would occasionally stand and walk over to someone, whisper in an ear, shake a hand. I wondered what the speakers thought would happen as the result of their varied petitions.

Then two doctors began to put all the divisions and inequities into context. Dr. Walter Tsou, well-fed and graying, first gave a PowerPoint presentation brimming with data about health disparities between various groups in America. We learned that the black infant-mortality rate is still double the white infant-mortality rate, that many doctors are strangely reluctant to recommend cardiac catheterization for elderly black women with chest pain, that Asian Americans had a significantly higher occurrence of hepatitis B than non-Asian Americans until 1993, when doctors began vaccinating all newborns against the disease. Remedying these disparities, Dr. Tsou said, was not a matter of repairing the health-care system. It was a matter of repairing everything. Your health is determined not only by your genes, after all, but also by your environment. And that environment is determined by the rules society itself sets up—rules about who lives in what place, who goes to what school, who gets what job. “Until we actually address the social determinants of health,” Dr. Tsou said, “we will not truly eliminate health disparities.”

The next speaker, Dr. Robert Zarr, continued the line of thought. “The single most important reason why we see these disparities is lack of health insurance,” he said, with staccato confidence. “That is the truth. It’s the truth for those of us who have gone periods of our lives without health insurance. It’s the truth for my patients.” Dr. Zarr explained that he is the director of pediatric medicine for a group of community health centers that process more than 60,000 pediatric visits a year, and that most of the children who come through have a shaky connection at best to any kind of benefits. Without insurance, he said, there was not much he could do for these kids. “What good is it if I write them a prescription for the antibiotic if they don’t have money to go to the pharmacy to get it? What good is it that I diagnose dysplasia of the hip of a baby if I can’t get him in to a specialist to get seen?”

A natural salesman, Dr. Zarr then asked his audience some leading questions. “What if I told you there’s an answer right now, right here and today? There is an answer to getting rid of this single most important barrier. Can anybody tell me what that answer is?” Several people in the audience, anticipating what would become a Dem ocratic campaign mantra, shouted out: “Universal health care!” But Dr. Zarr was indignant. “Not just universal health care—even President Bush talks about universal health care!—single-payer universal health care.” Then he lowered his voice. “Now let me tell you why. HR 676 clearly is going to give lifetime, comprehensive, quality access to care to every single American. Keep it simple. That’s what it is going to do.”

This was a strong claim, of course. Single payer would not end racism. Poor people would still be poor and sick people would still be sick. There was no doubt, though, that in a single-payer system the whole idea of “forgotten groups” simply could be eliminated. Instead of separating the healthy from the sick, the high-risk from the low-risk, the rich from the poor, a single payer would unite all Americans into a single system. There would be no tiers, no ghettos, no red lines, at least not in terms of access to health insurance, because a single payer—the government—would cover everyone.

There was one phrase we had to remember, Dr. Zarr said, and it was this: Everybody in, nobody out. “Say it with me. Everybody in, nobody out.

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is a senior editor of Harper’s Magazine.

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