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Dare to Be 100: Obamacare -- Wishful or Mandate of a Civil Society?

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Abraham Lincoln on government, July 1, 1854: "The legitimate object of government is to do for a community of people whatever they need to have done, but cannot do, at all, or cannot, so well do, for themselves -- in their separate and individual capacities." (1)

The American tattered health care system hurts everywhere. It is disorganized, inconsistent, inefficient, corrupt, and dangerous. But the two most outrageous degradations are cost and injustice. Martin Luther King Jr. said "of all the forms of inequality and injustice health care is the most shocking and inhumane." (2) In the Republic, Plato noted that the dominant responsibility of the polis is equality. (3)

Despite the nobility of such statements America has laid outside the margins of all the other developed countries of the world with respect to access. Until 1965 one-half of all older Americans lacked basic health insurance and therefore access to adequate care (see references below). Lyndon Johnson faced up to this reality, and against much opposition led the passage of Medicare with John Gardner's firm hand at the tiller. Medicare was passed and has remained a bulwark of our society since.

Still, America has remained a stigma because we are the only developed nation that lacks a universal health care insurance system for all. Every indication insists that such unequal access accounts for much of the degraded status of our system that ranks very low in the order of world nations.

To his manifest credit Obama confronted this issue and proposed the first major legislation since Medicare to address restricted access. The resultant Obamacare program is just being initiated and has many administrative details to be ironed out. In light of the disgraceful state of Congress it is a virtual miracle that he was able to initiate such a critical advance, again against much opposition. The program nonetheless has been endorsed by the Supreme Court and is the law of the land.

It is unfair to judge Obamacare at first glance. It must have the opportunity to work just as Medicare needed time. It staggers the imagination to consider the challenge posed by the requirement to provide the administrative infrastructure to create a new program for 40 million unique customers, each with individual wants and needs.

Yet, while the Obamacare access initiative is necessary, it is insufficient. It provides universal access, but the immediate question is access to what? Until the current legislative initiative addresses the cost issue any judgment is moot.

In my view the program of Alain Enthoven, first proposed 35 years ago, is the next frontier for legislation. (4) It involves the proposal for Managed Competition, which encompasses both the need for regulation and the need for a competitive environment. Some adaptation of this program has become the operational protocol for the Netherlands and is called Enthovencare.

It is not too early to look at the package that is to be vouchsafed through our citizenry. It is my contention that the entire medical culture requires a new paradigm in which health replaces disease as the focal point for the medical scheme. Health must pay. This reality needs to be imprinted on the next addition beyond Obamacare.

The new paradigm of health emphasizes prevention rather than repair. This is the next challenge of our political system that too generously rewards profit instead of justice.

Such a goal is wishful. But if our America is to be viewed as a successful democracy then we must move on. We must heed this mandate.


1) Lincoln ,A. Fragment on Government, July 1,1854. In The Collected Works of Abraham Lincoln. Ed. Basler RP,Vol.2.p.220-221.

2) King, ML Jr. Cited by Hilary Clinton at World Health Assembly May 14,1995.

3) Plato, The Republic.

4) Enthoven AC. Consumer Choice Health Plan. Inflation and Inequity in Health Care Today with Alternatives for Cost Control and an Analysis of Proposals for National Health Insurance. New Engl. J. Med 1978;288:650-658.