ROBERT SIEGEL, HOST:
Senate Republicans have scrapped their latest plan to repeal the Affordable Care Act. They say the Graham-Cassidy bill did not have enough votes to pass. For now, Obamacare remains the law of the land. But big questions about the future of health care remain, questions like, is health care a right?
Surgeon and New Yorker writer Atul Gawande put that question to people in Athens County, Ohio, where he grew up. The answers Gawande heard said much about people's attitudes toward the Affordable Care Act, Medicare and Medicaid. Atul Gawande, welcome back to the program.
ATUL GAWANDE: Glad to be on.
SIEGEL: First, tell us about Athens County, Ohio, and the people you interviewed for this story.
GAWANDE: Well, it's a rural county. It's poor. It's in the Appalachian foothills in southeastern Ohio. And the people I grew up with and then their friends that they connected me to were people who were still back home, many not doing financially fabulously. And the interesting thing was the answer I got when I asked people about whether health care should be a right. They said no often, even people who had been bankrupted by their health care costs.
SIEGEL: Well, when they said, no, I don't think it's a right, did they then say it's a privilege, it's something that you have to work for? What - how do they regard health care?
GAWANDE: No. When you said it's a right, what they called to mind was that they are getting a very different deal for health care than people they see around them. Monna French graduated the same year from high school that I did, became the librarian at Athens Middle School. Now, after 22 years, is only making $17 an hour, pays half of her paycheck in taxes and premiums for what turns out to be crummy insurance with a $3,000 deductible.
And her frustration is that meanwhile, those taxes are going to pay for others in her own neighborhood that she sees who are getting a Medicaid card with better coverage than she can dream of - no deductibles, no co-pays, no premiums. That's when she responds by saying, should there be a right to health care? No, because what she hears that as - who else am I supposed to be paying for now, too? I can't even afford what I've got.
SIEGEL: You mention Medicaid, people who might have looked at those with lower incomes than their own, envious of the health care they got through Medicaid. But Medicare was something different. They didn't have the same problem with Medicare.
GAWANDE: Yeah, that was the interesting thing, is that we were in a situation where people were divided on whether government-guaranteed health care was a good idea but fully supportive of Medicare. When we think of the health system for people over 65, it is very much rooted in the Social Security ethic of we all pay in and then we all benefit equally. And whatever may happen happens. Some people will benefit more. Some people will benefit less. Medicaid, however, is a program that's seen as the poorest get some of the best coverage there is. So that sense that we're in it together is what's broken.
SIEGEL: But which do you think the problem is here, that somehow the system has not been engineered well enough to make sure that people getting Medicaid are not doing better than people who are getting insurance on the exchanges or that the very idea of having two different ways of delivering health care is fundamentally wrong and that we'll never get that zone of moral hazard right?
GAWANDE: It's the latter. We're locked into this zero-sum game. It's sort of like being in that airport security line where I'm in zone 5 and why does the person in zone 6 jump the line ahead of me and somehow get a better deal? You know, when you compare it to the way we take care of roads and schools and other basic needs that we have to count on others to contribute towards, we've all gone in together. We don't have a different lane where you have a higher co-pay on your lane if you're in one job or if you happen to earn a certain amount. We're all on those roads together.
SIEGEL: In some states, there are moves to have a work requirement for Medicaid eligibility. To my knowledge, no one has yet proposed in recent decades that if you're not working your kids don't have a right to a public education. What is it that's so different about health care that makes us say, wait a minute, why are you getting access to coverage and you're not pulling your weight economically?
GAWANDE: I think this ties to the core problem that we, going back now to World War II, linked where you get health care to your job. We didn't do that with our roads. We didn't do that with your schools. But when we did that with this thing that is incredibly important to your life and well-being, it's proved to be a mistake because we then have to figure out, how do we construct systems to capture people who aren't covered by their job - small businesses, self-employed, disabled and so on?
And then each of them get a different deal we end up fighting over. Now, the most creative state efforts to solve this are ones like in Nevada. The legislature passed a program that would have allowed people to buy into the state Medicaid program. And that would have shifted it from being a welfare program to a program open to all on their basis of their ability to pay. Those kinds of experiments are going to be the future of where we go. It was too bad the governor vetoed that plan.
But that kind of program - buy into Medicaid, buy into Medicare, an open system that allows people to get in according to their ability to pay - that comes closer to enacting the values that people were describing to me when I went back home.
SIEGEL: Atul Gawande is a surgeon and staff writer for The New Yorker. His current article is "Is Health Care A Right?" and his book, "Being Mortal," is now out in paperback. Thanks for talking with us.
GAWANDE: Many thanks.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.