The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.—Hubert Humphrey
These are the words that physician Donald Berwick saw as he went to work in the building that bears Humphrey’s name and houses the US Department of Health and Human Services in Washington, DC. They reminded Berwick, the former administrator of the Centers for Medicare & Medicaid Services (CMS), of his most important mission: “to help the people who need our help the most.” And they are at the heart of an important topic of debate during this election season: what is the proper role of government in our lives?
The attention paid to the Affordable Care Act (ACA) during the presidential race clouds other issues, such as what to do about Social Security. Current projections are that the Social Security Trust Fund will be unable to meet its payment obligations sometime between 2036 and 2041, if legislative reform is not forthcoming. Although both the Democratic and Republican platforms include references to Social Security, only President Obama mentioned it in his address. While Social Security may seem at first glance to be peripheral to health care, it’s really not, as I’ll explain.
In 1985, my 28-year-old brother, David, lived in Pittsburgh with his family and worked as a welder, a trade he pursued after finishing a tour of duty in the US Army. But the “Steel City” was in decline, and he took a job at a nonunion shop, where workers were paid minimum wage, worked overtime to make ends meet, and still qualified for state assistance such as fuel subsidies and the Women, Infants, and Children (WIC) nutrition program for low-income families.
Working overtime the night before Thanksgiving, David used a forklift to stabilize a 7-ton piece of metal tongs (the company didn’t have the proper equipment). The forklift gave way, and the giant steel tongs fell on my brother. He was killed instantly.
David left behind a wife, whose unpaid job was as mother to their 4 children, ages 9 months to 9 years. Fortunately, he had paid Social Security taxes long enough to qualify his family for the death and survivor benefits—which kept them from abject poverty.
My brother’s family is one of many to benefit from this safety-net program. When Republican vice presidential candidate Paul Ryan (R, Wis) was 16 years old, his father—a lawyer—died suddenly at the age of 55 years, and Ryan, his mother, and 3 older siblings also received Social Security benefits. Ryan put his monthly Social Security checks in a savings account, as is permitted by law, and used the savings to attend college. By most accounts, Ryan acquired his political philosophy from that college experience, one that’s been described as focusing on “individual rights, distrust of big government and an allegorical embrace of the Founding Fathers.”
The irony of Paul Ryan is that this proponent of limiting the role of government has also been its beneficiary. He wants to privatize Social Security—which might work for some workers, but for others, it could undermine the survivor and disability benefits. President Ronald Reagan said in his 1981 inaugural address, “Government is not the solution to our problem; government is the problem.” Influential tax reformist and Reagan devotee Grover Norquist has continued the charge against any Congressional proposals to increase the government’s revenues through taxes: “My goal is to cut government in half in twenty-five years to get it down to the size where we can drown it in the bathtub.”
The ACA is resulting in new regulations that some clinicians and institutions find concerning. But the law was passed in part because the private sector was unable to address the nation’s escalating health care costs and comparatively poor outcomes. If the nation depends on a healthy citizenry for economic success, then strategies for reducing the number of uninsured people and improving access to safe, quality, equitable health care are imperative. The ACA lays the foundation for achieving both by expanding and reforming health insurance coverage. And it does more. Through the new CMS Center for Medicare & Medicaid Innovation, it seeds demonstration and pilot projects to allow experimentation with new ways of paying for and delivering care.
The law also includes funding to test ways to improve transitional care, keep older adults in their own homes instead of nursing homes and hospitals, reduce the risks for at-risk mothers and their infants, and invest in wellness programs. Berwick knew his time at the CMS was short and worked hard to launch the agency’s implementation of the ACA as nimbly and creatively as possible, given the federal bureaucracy in which he was operating. He knew that any bureaucracy—whether public or private—could slow down the pace of innovations that are so needed in reforming health care.
But health care does not provide the sole solution to improving health. As William Foege, MD, MPH, Senior Fellow for the Global Health Program of the Bill and Melinda Gates Foundation, has argued, poverty is the most important social determinant of adverse health outcomes. Social Security can provide a crucial government safety net for older adults who can no longer work and have no income, for many adults with disabilities, and for the children and spouse of a working parent who dies. It provides monthly benefits to 38.5 million retirees, 10.6 million disabled people, and 6.3 million survivors of deceased workers. It is the only income for 16% to 33% of these beneficiaries.
My brother’s children and his wife were fortunate that he was such a consistent worker. They are all now educated, productive people. They all pay taxes that will likely amount to more than they ever received as Social Security beneficiaries. They were helped by a federal program designed, in part, to help people who need it most.
About the author: Diana Mason, PhD, RN, is the Rudin Professor of Nursing and Co-Director of the Center for Health, Media, and Policy at the Hunter College, City University of New York, and President-elect of the American Academy of Nursing.
About The JAMA Forum: To provide ongoing coverage throughout this election year, JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide insight about the political aspects of health care. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.