As the U.S. Senate’s stormy health care melodrama staggered closer to a conclusion last week, one suspects local resident Marilyn Ratkin might have wished it had done so earlier – months earlier.

For one thing, had a bill been readied for passage during the fall as President Barack Obama had originally hoped, it might have been more favorable toward an expansive role for the federal government in promoting universal coverage. It might have featured stronger regulations some say are needed to keep insurance providers in check. An autumn bill might even have included a robust public option, dreamed of by a generation of progressives, designed to promote competition in the industry and extend coverage to millions who presently lack it.

Also, the weather would have been better.

“I don’t mind standing in the heat but I had to have cared about health care to have gone out in that cold,” chuckled Ratkin, who rallied for reform in front of U.S. Senator Christopher Bond’s office on a December day when the thermometer struggled to crack 30 degrees. “People have a right to have health care, to have access. They have a right to see a doctor within a reasonable length of time. It’s a human right.”

The enthusiasm that kept Ratkin so warm during last week’s cold spell is indicative of the passion felt by both sides in a heated, protracted and at times maddeningly slow debate over health care reform where opinions run the gamut from staunch backers of a single-payer system to firm opponents of any role for federal government involvement.

In the latest developments, early Monday morning the U.S. Senate quashed a Republican-inspired filibuster on a 60-40 party-line vote after feverish negotiations between moderate and liberal Democrats resulted in the elimination of the public option provision and stricter language on abortion funding. The measure is expected to head to a final vote later this week. The public option was included in the House version of the bill, which passed narrowly early last month, but is likely to die in the final legislation.

Government’s role

Ratkin is the point person for the St. Louis Section of the National Council of Jewish Women on the health care issue. She said that while the present system functions well for some, she thinks it fails many others.

“I really feel that what we have now is not working,” she said. “It’s great for people like me. I canafford good health care. I don’t think it’s going to change my health care access.”

On that point, however, not everyone shares Ratkin’s optimism.

“Whether the people in charge are Democrats or Republicans I have my doubts about anything the government is in charge of,” said Marvin Plattner, 75. “I’m satisfied with what I’ve got now.”

Perhaps ironically, what Plattner, who suffers from heart trouble and diabetes, has now is primarily provided by the government, specifically in the form of Medicare and veteran’s benefits, two things he fears may be negatively affected if reform passes and reshuffles federal priorities. Opponents have said that cuts to Medicare to pay for the overhaul may impact the level of care seniors receive and that’s driven concerns like those voiced by the St. Louis County retiree that his quality of life could suffer.

Plattner said that the uninsured already receive emergency care from hospitals and expressed deep skepticism that the government could do anything to improve their situation without harming his own or others.

“I doubt if they could get it right,” he said.

While such arguments may bring both sides of the debate into sharp relief, others express opinions that reveal the health-care issue to be more than a two-sided coin.

“I think the devil is in the details,” said Jeffrey Kass, a University City attorney, “and I’m not quite sure what the right answer is. I certainly have concerns about the government running a health insurance program when it can’t even do ‘Cash for Clunkers’ correctly.”

Though he may echo Plattner’s fear of far-reaching legislative prescriptions, Kass sounds remarkably like Ratkin when analyzing the problem.

“There are tens of millions of Americans who don’t have health insurance and I think we have to do something about that,” he said. “I do think it is a fundamental human and American right to have health care.”

Kass said he feels that the present system of private insurance is clearly faltering as costs spiral out of control. Government deficits also concern him though he suggests that proposed taxes on soft drinks might be a potential solution. Overall, he said he doesn’t oppose the concept of spending money. He’s just concerned about whether it would be spent well.

“I’m not one of these libertarians who think that the government should stay out of our lives,” he said. “I think that if the government can help and the private sector is not doing a good job then the government should get involved.”

Still, he worries about the prospect of government offering its own insurance. While it might promote competition, Kass said that that competition wouldn’t be on a level playing field and might drive private insurance out of business.

“The public option means that the government is going to compete with the private health insurance industry,” he said, “but the problem is that the government has a printing press for money and private insurance doesn’t have that. I think there is a danger that it ultimately goes to a system where we end up with only one option.”

Kass said that, as important as the health-care drama is, its unhappy side effect is that the issue is blotting out broader concerns, such as unemployment. The more people who have jobs, he said, the smaller the number of uninsured. While he doesn’t necessarily agree with Obama on health care, he does think it’s sad that the president’s poll numbers seem to rise and fall so heavily on just one issue.

“The issues are just so much more complex than that and I think it’s far too early to tell whether the president is doing a good or bad job,” he said. “The unfortunate fallout from health care is that other issues are going to be affected.”

Morality, money and a mammogram

Some, however, think the issue needs all the attention it can get. Stephen Radinsky, a retired radiologist, used to spend one week a year giving mammograms to the uninsured. He still remembers one patient he saw who had a malignancy.

“She stood there and stared at me and said, ‘you don’t understand, I don’t have health insurance, what do I do now?'” he recalled her saying. “It’s a million-dollar illness. Here I had a young lady who had a curable cancer most likely, and basically I had to tell her that she had to go home and die.”

Radinsky’s displeasure with the insurance companies is palpable. He blames them for most of the system’s ailments saying he believes they are more concerned with profits and CEO compensation packages than with people. He feels the industry’s anti-trust exemption and laws that prevent companies from selling across state lines are creating virtual monopolies in some areas of the country. He favors a public option to bring down costs and says fears it would drive private insurance out of business are unfounded. He says estimates are that less than a tenth of the population would use the government-sponsored alternative.

“We need competition against the insurance companies. Otherwise, this won’t work,” said Radinsky, who noted that last week his own wife’s insurance premium jumped from $430 a month to $551, even though she is healthy. “Companies in this country can’t afford to pay for health care.”

Almost three years ago, Radinsky co-founded Missouri Health Care for All, a faith-based organization comprising 120 groups favoring reform. At one point, Radinsky and Central Reform Congregation Rabbi Susan Talve, another person who helped put the group together, even spent two years researching and writing a reform plan that they proposed to the Missouri legislature. Both were fellow attendees with Ratkin at last week’s sub-freezing rally, which was sponsored by the group.

For Talve, the issue hits home. Her daughter was born with a heart defect that eventually resulted in a transplant at age 19. Talve’s son also had medical issues, which arose in his mid-20s. While he is fine now, Talve worries about what could have happened had circumstances been different.

“I can imagine if it were a family that had lost their job or is really living on the edge, he would not have gone to the doctor when he did,” she said, “and he would not have gotten the kind of care that saved his life.”

It’s also not uncommon, she said, for those in her son’s age group to do without insurance altogether either to save money or because they don’t feel they need it. That means that if a serious illness does arise, they can become effectively uninsurable, shackled with a preexisting condition.

The requirement that insurance companies cover such illnesses is one of many reasons Talve supports the present bill. She said that while the Senate version has removed a number of provisions she favors, she feels progressives will be able to resolve issues favorably when the differing measures are reconciled in conference committee. The most important thing is to get the bill passed, Talve said.

“I think it’s so unfair when I hear these legislators say it’s going to cost too much because the kind of preventions that are built into both bills are going to cut costs,” she said. “We are talking about health care, not sick care, which is what we have now. People are making a lot of money taking care of sick people. They want to see sick care continue.”

Solutions or more problems?

But Maurice Weingart sees it differently. Costs, he said, are a concern.

“Being as I am 88 years old now, it’s not going to bother me a lot,” he said. “But our kids and grandchildren will be paying for it.”

The price tag for the package is big – more than a trillion dollars in the House version of the bill, less than $900 billion in the new Senate compromise – over the next 10 years. However, congressional budget analysts predict that taxes and spending cuts in both bills would actually reduce the deficit slightly over that period. The Senate bill would provide about $132 billion in deficit reduction. It will also provide a little less than $400 billion in new taxes.

Weingart, who spent nearly a half century selling general insurance, said that people should be able to decide for themselves whether they want financial protection or not and worries that requiring companies to cover preexisting conditions, considered by reformers as a key component of any plan, could be disastrous. Outside of perhaps giving subsidies to the needy, he sees little Congress can do to help the situation. Further, he worries that providers may flee the market if it tries.

“If the government is going to undercut them, they’ll stop writing policies,” he said of insurance companies, “especially when the government says you must cover everything, even people with diseases that you know are going to be costly.”

Local attorney Mark Mittleman is also not convinced.

“They have not made the case to me that whatever kind of massive bureaucratic solution they’re attempting to impose, whose details we don’t even know about, is really going to bring about any benefit to most citizens,” he said. “It may benefit a few at the expense of a lot of others and it may not be much of a benefit even to them.”

Dr. Gary Ratkin, Marilyn Ratkin’s husband, might agree that the health care question is a complex one but, like his wife, he thinks the government should play a bigger role.

“I think our goal has to be to provide health care for as close to 100 percent of Americans as possible,” said Ratkin, a hematologist/oncologist and medical director of the Missouri Baptist Hospital Cancer Center. “In order to do this, we have to come to grips with the costs that are currently out of control in our system. There are multiple contributors to those costs that I don’t think Congress has completely tackled.”

Dr. Ratkin said that those cost overruns emanate from a confusing triangle composed of the pharmaceutical industry, health insurance companies and hospitals, each contributing their own problems to the system. He said expanding Medicare, an idea that was proposed – and then killed – in the Senate might be a partial solution. However, Medicare hasn’t had much success with the pharmaceutical companies in bringing down costs, he said, whereas the Veterans Administration has.

“I think that if we could adopt various successes and depoliticize this whole debate we might come out with a more realistic system,” he said.

Unfortunately, he noted that the bitterly partisan nature of the issue, something he blames on both sides, has hobbled it as abortion and other hot button issues have taken over the headlines.

Still, he said, Medicare, though controversial, did not seem as fiercely partisan as 2009’s debate has been. Even if the issue were less political, how much more solvable it would be is uncertain. In any event, the scope and complexity of the problem can only elicit a tired chuckle from a 67-year-old oncologist used to dealing with the most difficult cases in his office every day. The tone of Dr. Ratkin’s voice seems to sum up his wife’s determination, Kass’s mixed feelings, Plattner’s Medicare worries, Weingart’s cost uneasiness, Talve’s concern for her children, Mittleman’s doubts about government, and Radinsky’s memories of an uninsured patient.

“There are no short answers to this,” he said.