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Is health care a right? What Ohio and Kentucky teach us.

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Have you read Atul Gawande's latest piece in the New Yorker? If not, go read it — I will wait!

Gawande's piece explores whether Americans view health care as a right or a privilege. In doing so, it uncovers what I've come to believe is a key driver of Obamacare opposition: resentment of "undeserving" poor people receiving comprehensive benefits.

And it comes out so clearly in Gawande's travels back to his hometown of Athens, Ohio, where he seeks to understand whether people "in the Appalachian foothills" see health care as something everyone has a right to.

One of the things he runs into again and again is an opposition to health care as a right for people who don't seem to deserve it. One woman he interviews, a librarian named Monna, tells him, "If you're disabled, if you're mentally ill, fine, I get it. But I know so many folks on Medicaid that just don't work. They're lazy."

Another man, Joe, puts it this way: "I see people on the same road I live on who have never worked a lick in their life. They're living on disability incomes, and they're healthier than I am."

As Gawande notes in his piece, "A right makes no distinction between the deserving and undeserving." But he often found this to be the key dividing line when he asked people whether everyone should have health coverage. Often, it came down to whether that person was the type who merited such help.

These interviews felt really familiar to me: It's something I've seen in my own reporting in Kentucky, where there was deep resentment of the idea that people who don't work get the lavish benefit package Medicaid provides.

In particular, there was one woman I met, whom I'll call Susan Allen (she asked me not to use her real name, because she didn't want people to know that she uses the Affordable Care Act for coverage).

Allen used to do administrative work in an elementary school but now is a caregiver to her elderly mother. Her husband has mostly worked in manual labor jobs, including the coal industry.

Allen told me a story about when she worked in the school. At Christmas, there would be a drive to collect present for the poorest families, presents she sometimes couldn't afford for her own kids. It made her upset.

"These kids that get on the list every year, I'd hear them saying, 'My mom is going to buy me a TV for Christmas,'" Allen says. "And I can't afford to buy my kid a TV, and he's in the exact same grade with her."

Allen saw her health insurance as the same story. She has a marketplace plan with a $6,000 deductible — so high that she often avoids going to the doctor unless she absolutely needs to. But people on Medicaid got a great plan without any copayments or deductibles.

"The ones that have full Medicaid, they can go to the emergency room for a headache," she says. "They're going to the doctor for pills, and that's what they're on."

One of the things that surprised me when I talked to Allen and others was that her problem wasn't really about the undeserving getting help — it was, in her framing, more about the fact that she deserved that same help too. Medicaid is often seen in Washington as the health plan of last resort, the one that has fewer doctors and lower payment rates. In Kentucky, Medicaid was seen as the jackpot — the insurance plan that lets you go to the doctor for no charge at all.

Allen made the case that if other people were getting Medicaid — and they didn't work — the fact that she does work in a job shouldn't disqualify her from that fantastic-sounding plan. An Obamacare worker I shadowed in eastern Kentucky repeatedly made the point to me on multiple occasions that we'd just be better off if we had a system like Canada's.

"Two sets of values are in tension," Gawande writes. "We want to reward work, ingenuity, self-reliance. And we want to protect the weak, and the vulnerable — not least because over time, we all become weak and vulnerable."

Medicaid was meant, in the Affordable Care Act, to serve as a safety net for especially vulnerable Americans. It wasn't even Congress's first choice for expanding coverage, but legislators included an expansion of the public program when they realized the costs of providing private coverage to all the uninsured would be prohibitively expensive (at least in the eyes of the Congressional Budget Office). But the decision to expand Medicaid has created an unexpected and important fault line, one that leads to bitter divides in some of the communities where the expansion has helped the most.

Chart of the Day


America’s teen birthrate has fallen by half over the past decade, a stunning public health victory. New federal data shows that the teen birthrate in the United States has declined from 41.5 births per 1,000 teenage girls in 2007 to 20.3 births per 1,000 teenage girls this year. Read more here.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

Analysis and longer reads

  • "Why Public Health Insurance Could Help, Even if You Don’t Want It": “India’s and Mexico’s experiences offer some of the best evidence on what happens when we add a public option to a marketplace: The private sector is forced to improve its game to retain customers, so more people benefit than just those who directly use the public services.” —Seema Jayachandran, New York Times
  • "Study challenges notion that emergency departments foster opioid misuse": “A team of researchers examined 5.2 million opioid prescriptions and found that in the ED opioid prescriptions exceeding seven days were 84 to 91 percent lower than in non-emergency settings, depending on insurance status.” —Beth Jones Sanborn, Healthcare Finance
  • "How Would ‘Medicare for All’ Help Health-Care Workers?": “The health-care-reform debate in Washington is finally starting to grapple with the equity gap in the health system for consumers, and momentum is gaining for a fairer government-run single-payer system. Yet, for all the promise of the 'Medicare for All' proposal, there’s surprisingly little discussion on how an overhaul of our health-care system would affect the people delivering our care.” —Michelle Chen, the Nation

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