Category Archives: Universal Health Care

Universal Health Care Start Dates

The graphic below shows those countries that adopted universal health care and the dates they did so. It also shows the dates those countries ended universal health care. Notice a pattern? They never did. But we are the only country to not offer universal health care, and are resisting doing so because of a medical-industrial complex that is greedy, profit-driven, wedded to an outdated ideological philosophy of the role of government and social services, including health care, all so that Wall Street, insurance companies, pharmaceutical companies, device manufacturers, large hospital systems, and consultants and service providers to the industry can get their cut of the pie. And notice that none of them are Socialist.

Medicare for All and Its Rivals | Annals of Internal Medicine | American College of Physicians

Richard’s Note: A shout-out to Don McCanne for posting this today from the Annals of Internal Medicine, which is providing the full article for free. The authors, Steffie Woolhandler and David Himmelstein, both MDs, should be familiar to readers as two of the authors I covered in my review of the Waitzkin, et al. book, Health Care Under the Knife: Moving Beyond Capitalism for Our Health. In the spirit of the AIM, I am posting the entire article below with link to the original. It is that important.

Medicare for All and Its Rivals: New Offshoots of Old Health Policy Roots

The leading option for health reform in the United States would leave 36.2 million persons
uninsured in 2027 while costs would balloon to nearly $6 trillion (1). That option is called the
status quo. Other reasons why temporizing is a poor choice include the country’s decreasing life
expectancy, the widening mortality gap between the rich and the poor, and rising deductibles
and drug prices. Even insured persons fear medical bills, commercial pressures permeate
examination rooms, and physicians are burning out.
In response to these health policy failures, many Democrats now advocate single-payer,
Medicare-for-All reform, which until recently was a political nonstarter. Others are wary of
frontally assaulting insurers and the pharmaceutical industry and advocate public-option plans
or defending the Patient Protection and Affordable Care Act (ACA). Meanwhile, the Trump
administration seeks to turbocharge market forces through deregulation and funneling more
government funds through private insurers. Here, we highlight the probable effects of these
proposals on how many persons would be covered, the comprehensiveness of coverage, and
national health expenditures (Table).

Table. Characteristics of Major Health Reform Proposals as of March 2019

Medicare for All

Medicare-for-All proposals are descendents of the 1948 Wagner–Murray–Dingell national health
insurance bill and Edward Kennedy and Martha Griffiths’ 1971 single-payer plan (2). They would
replace the current welter of public and private plans with a single, tax-funded insurer covering
all U.S. residents. The benefit package would be comprehensive, providing first-dollar coverage
for all medically necessary care and medications. The single-payer plan would use its
purchasing power to negotiate for lower drug prices and pay hospitals lump-sum global
operating budgets (similar to how fire departments are funded). Physicians would be paid
according to a simplified fee schedule or receive salaries from hospitals or group practices.
Similar payment strategies in Canada and other nations have made universal coverage
affordable even as physicians’ incomes have risen. These countries have realized savings in
national health expenditures by dramatically reducing insurers’ overhead and providers’ billing-
related documentation and transaction costs, which currently consume nearly one third of U.S.
health care spending (3). The payment schemes in the House of Representatives’ Medicare-for-
All bill closely resemble those in Canada. The companion Senate bill incorporates some of
Medicare’s current value-based payment mechanisms, which would attenuate administrative
savings. Most analysts, including some who are critical of Medicare for All, project that such a
reform would garner hundreds of billions of dollars in administrative and drug savings (4) that
would counterbalance the costs of utilization increases from expanded and upgraded coverage.
Reductions in premiums and out-of-pocket costs would fully offset the expense of new taxes
implemented to fund the reform.

 

“Medicare-for-More” Public Options

Public-option proposals, which would allow some persons to buy in to a public insurance plan,
might be labeled “Medicare for More.” Republicans Senator Jacob Javits and Representative John
Lindsay first advanced similar proposals in the early 1960s as rivals to a proposed fully public
Medicare program for seniors. This approach resurfaced during the early 1970s as Javits’
universal coverage alternative to Kennedy’s single-payer plan and gained favor with some
Democrats during the 2009 ACA debate.
Policymakers are floating several public-option variants, most of which would offer a public plan
alongside private plans on the ACA’s insurance exchanges. Although a few of these variants
would allow persons to buy in to Medicaid, most envision a new plan that would pay Medicare
rates and use providers who participate in Medicare. Positive features of these reforms include
offering additional insurance choices and minimizing the need for new taxes because enrollees
would pay premiums to cover the new costs. However, these plans would cover only a fraction
of uninsured persons, few of whom could afford the premiums (5); do little to improve the
comprehensiveness of existing coverage; and modestly increase national health expenditures.
The Medicaid public-option variant, which many states might reject, would probably dilute
these effects.
Medicare for America, the strongest version of a public-option plan, would automatically enroll
anyone not covered by their employer (including current Medicare, Medicaid, and Children’s
Health Insurance Program enrollees) in a new Medicare Part E plan. It would upgrade
Medicare’s benefits, although copayments and deductibles (capped at $3500) would remain.
The program would subsidize premiums for those whose income is up to 600% of the poverty
level, and employers could enroll employees in the program by paying 8% of their annual
payroll. The new plan would use Medicare’s payment strategies and include private Medicare
Advantage (MA) plans (which inflate Medicare’s costs [6]) and accountable care organizations.
Medicare for America would greatly expand coverage and upgrade its comprehensiveness but
at considerable cost. As with other public-options reforms, it would retain multiple payers and
therefore sacrifice much of the administrative savings available under single-payer plans.
Physicians and hospitals would have to maintain the expensive bureaucracies needed to
attribute costs and charges to individual patients, bill insurers, and collect copayments. Savings
on insurers’ overhead would also be less than those under single-payer plans. Overhead is only
2% in traditional Medicare (and 1.6% in Canada’s single-payer program [7]) but averages 13.7%
in MA plans (8) and would continue to do so under public-option proposals. Furthermore, as in
the MA program, private insurers would inflate taxpayers’ costs by upcoding as well as cherry-
picking and enacting network restrictions that shunt unprofitable patients to the public-option
plan. This strategy would turn the latter plan into a de facto high-risk pool.

The Trump Administration White Paper and Budget Proposal

Unlike these proposals, reforms under the Trump administration have moved to shrink the
government’s role in health care by relaxing ACA insurance regulations; green-lighting states’
Medicaid cuts; redirecting U.S. Department of Veterans Affairs funds to private care; and
strengthening the hand of private MA plans by easing network-adequacy standards, increasing
Medicare’s payments to these plans, and marketing to seniors on behalf of MA plans. A recent
administration white paper (9) presents the administration’s plan going forward: Spur the
growth of high-deductible coverage, eliminate coverage mandates, open the border to foreign
medical graduates, and override states’ “any-willing-provider” regulations and certificate-of-
need laws that constrain hospital expansion. The president’s recently released budget proposal
calls for cuts of $1.5 trillion in Medicaid funding and $818 billion in Medicare provider payments
over the next 10 years.
Thus far, the effects of the president’s actions—withdrawing coverage from some Medicaid
enrollees and downgrading the comprehensiveness of some private insurance—have been
modest. His plans would probably swell the ranks of uninsured persons and hollow out
coverage for many who retain coverage, shifting costs from the government and employers to
individual patients. The effect on overall national health expenditures is unclear: Cuts to
Medicaid, Medicare, and the comprehensiveness of insurance might decrease expenditures;
however, deregulating providers and insurers would probably increase them.
In 1971, a total of 5 years after the advent of Medicare and Medicaid, exploding costs and
persistent problems with access and quality triggered a roiling debate over single-payer plans.
As support for Kennedy’s plan grew, moderate Republicans offered a public-option alternative,
1 of several proposals promising broadened coverage on terms friendlier to private insurers.
Kennedy derided these proposals by stating, “It calms down the flame, but it really doesn’t meet
the need” (10). President Nixon’s pro market HMO strategy—a close analogue of the modern-
day accountable care strategy—ultimately won out, although his proposals for coverage
mandates, insurance exchanges, and premium subsidies for low-income persons did not reach
fruition until passage of the ACA.
Five years into the ACA era, there is consensus that the health care status quo spawned by
Nixon’s vision is unsustainable. President Trump would veer further down the market path.
Public-option supporters hope to expand coverage while avoiding insurers’ wrath. Medicare-
for-All proponents aspire to decouple care from commerce.

Health Care Is Not a Market

For the next twenty-one months, there will be a national debate carried on during the presidential campaign regarding the direction this country will take about providing health care to all Americans.

However, to anyone who reads the articles, posts and comments on the social media site, LinkedIn, that debate is already occurring, and most of it is one-sided against Medicare for All/Single Payer. The individuals conducting this debate are for the most part in the health care field, as either physicians, pharmaceutical industry employees, hospital systems executives, insurance company executives, and so on.

We also find employee benefits specialists and other consultants to the health care industry, plus many academics in the health care space, and many general business people commenting, parroting the talking points from right-wing media.

That is why I re-posted articles from my fellow blogger, Joe Paduda last week and yesterday,  who is infinitely more knowledgeable than I am on the subject, and has far more experience in the health care field, that not only predicts Medicare for All (or what he would like to see, Medicaid for All), but has vigorously defended it and explained it to those who have misconceptions.

For that, I am grateful, and will continue to acknowledge his work on my blog. But what has caused me to write this article is the fact that most of the criticism of Medicare for All/Single Payer is because those individuals who are posting or commenting, are defending their turf.

I get that. They get paid to do that, or they depend on the current system to pay their salaries, so naturally they are against anything that would harm that relationship.

But what really gets me is that they are deciding that they have the right to tell the rest of us that we must continue to experience this broken, complex and complicated system just so that they can make money. And that they have a right to prevent us from getting lower cost health care that provides better outcomes and does not leave millions under-insured or uninsured.

However, not all these individuals are doing this because of their jobs. Some are doing so because they are wedded to an economic and political ideology based on the free market as the answer to every social issue, including health care. They argue that if we only had a true free market, competitive health care system, the costs would come down.

But as we have seen with the rise in prices for many medications such as insulin and other life-saving drugs, the free market companies have jacked up the prices simply because they can, and because lobbyists for the pharmaceutical industry have forced Congress to pass a law forbidding the government from negotiating prices, as other nation’s governments do.

Yet, no other Western country has such a system, nor are they copying ours as it exists today. On the contrary, they have universal health care for their citizens, and by all measures, their systems are cheaper to run, and have better outcomes.

None of these countries can be considered “Socialist” countries, and even the most anti-Socialist, anti-Communist British Prime Minister, Winston Churchill said the following, “Our policy is to create a national health service in order to ensure that everybody in the country irrespective of means, age, sex or occupation shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

Notice that Sir Winston did not say, free market competition. He knew that competition is fine for selling automobiles, clothing, food, and other goods and services. But not health care.

He also said that you can always count on Americans to do the right thing, after they have tried everything else. We’ve tried the free market in health care, and drug prices and other medical prices are through the roof.

However, another thing they have not done, and I believe none of the other OECD countries have done about health care, is to divide the “market” into silos such as the elderly with Medicare, the poor with Medicaid, children with CHIP, veterans with the VA, and their families with Tricare, etc.

No, they pay for all their citizens from a global budget, and do not distinguish between age level, income level, or service in the armed forces.

And their systems do not restrict what medical care their people receive, so that no only do they have medical care, but dental care, vision care, and hearing care. It is comprehensive. And if they have the money to pay for it, they can purchase private health insurance for everything else.

In the run-up to the debate and vote in the UK on Brexit, the point was raised that while Britain was a member of the EU, their retirees who went to Spain to retire, never had to buy insurance because the Spanish providers would bill the NHS.

However, once Britain leaves the EU, they will have to buy insurance privately, because the NHS won’t pay for it. But not all retirees can afford private insurance, so many British citizens will have a problem.

As I have mentioned before in this blog, I was diagnosed with ESRD, and am paying $400 every three months for Medicare Part B. I was doing so while spending down money I received after my mother passed away in 2017. My brother and I sold her assets and used that money to purchase property so that she could go on Medicaid, and eventually into a nursing home when the time came for her to be cared for around the clock.

Since my diagnosis, and prior, I was not working, so spending $400 every three months, and paying for many of my meds, has been difficult. I am getting help with some of the meds, and one is free because my local supermarket chain, Publix gives it for free (Amlodipine).

I hope to be on Medicaid soon, but would much rather see me and my fellow Americans get Medicare for All, and not have to pay so much for it. (a side note: we have seen that Medicaid expansion has been haphazard, or reversed, even when the government is paying 90% of it)

So why are we not doing what everyone else does? For one thing, greed. Drug companies led by individuals like Martin Shkreli, who is now enjoying the hospitality of the federal government, and others are not evil, they are following the dictates of the free market that many are advocating we need. No thanks.

For another, Wall Street has sold the health care sector as another profit center that creates a huge return on investment by investors and shareholders in these companies and hospital systems. Consolidation in health care is no different than if two non-health care companies merge, or one company buys another for a strategic advantage in the marketplace.

There’s that word again: market. We already have a free market health care system, that is why is it broken. What we need is finance health care by the government and leave the providing of health care private. That’s what most other countries do.

So those of you standing in the way of Medicare for All/Single Payer, be advised. We are not going to let you deny us what is a right and not a privilege. We will not let you deny us what every other major Western country gives its people: universal, single payer health care.

Your time is nearly up.

Hospital lobby ramps up ‘Medicare for all’ opposition | Healthcare Dive

Sound the alarm bells, the health care industry is trying to prevent Americans from having the same kind of health care other Western industrialized countries give their citizens — universal health care; in this case, an improved and expanded Medicare-for-All.

Instead, they want to perpetuate the current system which by all accounts, is failing to provide quality health care at affordable costs, with better outcomes.

And the tactic they are using is fear-mongering of the worse kind, saying that if we move towards a Medicare-for-All system, the people who like their employer-based health care, or the hospitals, insurance companies, pharmaceutical companies, etc., will lose what they have, hospitals will close, and companies go bankrupt; in other words, they will lose huge profits the current broken system generates for them.

As the following article from Healthcare Dive reports, the hospital lobby is opposing this movement towards a more equitable system of health care in this country all for the purpose of protecting their bottom lines.

Don’t let them scare you. Universal health care is a right, not a privilege. We are the only Western industrial nation without such a system. People before profits. Health care for all, not for the few.

Here is the article:

As more Democratic presidential hopefuls embrace the idea, health systems and providers have picked up lobbying efforts arguing it would shutter hospitals.

Source: Hospital lobby ramps up ‘Medicare for all’ opposition | Healthcare Dive

ACA Declared Unconstitutional: Now What?


In another example of how cruel and inhumane the radical Conservative/Libertarian Republican Party has been regarding health care, a Federal judge in Texas late Friday, struck down the Affordable Care Act as unconstitutional.

The judge, Reed O’Connor, appointed by George W. Bush, struck down the law on the grounds that its mandates requiring people to buy health insurance is unconstitutional and the rest of the law cannot stand without it, as reported yesterday in the New York Times.

According to the Times article, the ruling was over a lawsuit filed earlier this year by a group of Republican governors and state attorneys general. States led by Democrats promised to appeal the decision, which will not have immediate effect.

However, the Times reports, it will make its way to the Supreme Court, where the survival of the law and the health of millions of Americans will be in doubt.
Judge O’Connor said, the Times quoted, that the individual mandate requiring people to have health insurance “can no longer be sustained as an exercise of Congress’s tax power.” In addition, the judge said, “the individual mandate is unconstitutional” and that the remaining provisions of the ACA are invalid.

The main issue, pointed out in the Times piece, was whether the law’s mandate still compelled people to buy coverage after Congress zeroed out the penalty as part of the tax overhaul this year.

20 states, led by Texas, argued that with the penalty zeroed out, the mandate had become unconstitutional, and that the rest of the law could not be severed from it, the Times wrote.

The Justice Department under former Attorney General Sessions, declined not to defend just the individual mandate, but the pre-existing conditions provision as well.

A spokesman for California attorney general Xavier Becerra said that California, and other defendant states, would challenge the ruling with an appeal in the US Court of Appeals for the Fifth Circuit in New Orleans.

Becerra’s statement, reported by the Times, said the following, “ Today’s ruling is an assault on 133 million Americans with pre-existing conditions, on the 20 million Americans who rely on the ACA’s consumer protections for health care, on America’s faithful progress towards affordable health care for all Americans…The ACA has already survived more than 70 unsuccessful repeal attempts and withstood scrutiny in the Supreme Court.”

The chief plaintiff in the case, Texas attorney general Ken Paxton, applauded the decision, and was quoted in the Times in a statement, “Today’s ruling enjoining Obamacare halts an unconstitutional exertion of federal power over the American health care system.”

Meaning that the American “health care system” can only be a private insurance-based system that allows companies to profit off some people’s health, or lack thereof. He is upholding the “right” of insurance companies, drug companies, medical device manufacturers, and others to profit at our expense and to play with the lives of millions of Americans who will lose what coverage the ACA gave them.

This also means, that any attempt to enact Medicare for All/single payer health care will result, at some future date, to a judge or court striking it down as unconstitutional.

Simply put, Conservative jurisprudence believes that the Constitution enshrines free-market health care.

The Times added that Paxton also said, “Our lawsuit seeks to effectively repeal Obamacare, which will give President Trump and Congress the opportunity to replace the ‘failed’ [quotes added] social experiment with a plan that ensures Texans and all Americans will again have greater choice (to be ripped off and overcharged) about what health coverage they need and who will be their doctor.”

In other words, Mr. Paxton wants the American health care system to stay where it is, so long as companies can make money from it.

Here are a few takeaways from the rest of the Times’ article:

• If the judge’s decision stands, about 17 million Americans will lose their health insurance, according to the Urban Institute. This includes millions who gained coverage through Medicaid expansion, and millions more who receive subsidized private insurance through the ACA marketplaces.
• Insurers will also no longer have to cover young adults up to age 26 under their parents’ plans
• Annual and lifetime limits on coverage will again be permitted
• And there will be no cap on out-of-pocket costs
• Also gone will be the law’s popular protections for people with pre-existing conditions

This last takeaway was front and center of the Democrats midterm campaigns, and while most Republicans insisted that they did not want to withdraw those protections, the article reported that most were silent after the ruling.

Without those protections, insurers could deny coverage to such people or charge them more; they could also return to charging them based on age, gender or profession, according to the Times.

The Kaiser Family Foundation, the Times noted, estimated that 53 million adults from 18 to 64 — 27 percent of that population would be rejected for coverage under practices in effect before the ACA.

Larry Levitt, senior vice president of the Kaiser Family Foundation wrote on Twitter, “If this Texas decision on the ACA is upheld, it would throw the individual insurance market and the whole health care system into complete chaos…But the case still has a long legal road to travel before that’s an immediate threat,” the Times quoted.

Democrats attacked the decision as absurd. Incoming House Speaker Nancy Pelosi said that when the party took control of the House next month, it would “move swiftly to formally intervene in the appeals process to uphold the lifesaving protections for people with pre-existing conditions and reject Republicans’ effort to destroy the Affordable Care Act.”

Healthcare Dive.com, in reporting Friday about the decision, wrote that a decision had been waiting in the wings since September, when the Justice Department asked Judge O’Connor to wait until the individual market’s open enrollment period ended, which was also a convenient time for Republicans running in the midterms.

Healthcare Dive.com also stated that the decision would be appealed to the conservative Fifth Circuit, and possibly to the Supreme Court, where advocates worry that it will be struck down.
Providers such as the American Hospital Association (AHA) and American Medical Association (AMA) urged a stay until a higher court could take it up.

One state not a part of the defendants was Maryland, according to Healthcare Dive.com. Maryland’s Democratic Attorney General, Brian Frosh, brought its own case seeking a reaffirmation of the ACA’s constitutionality.

Attorney General Frosh argued that Maryland residents who became insured under the ACA would be harmed if the law was unconstitutional or eliminated. About 150,000 people in Maryland gained insurance through the ACA marketplace in 2018, and more than 300,000 are insured through the state’s expanded Medicaid program.

The Maryland case is still ongoing.

So now what?

In the short-term, nothing will change, as mentioned in the two articles above. However, in the long-term, there will be serious consequences, just as Larry Levitt said on Twitter Friday.

But more importantly than chaos in the insurance market and health care system, millions of Americans will once again be at the mercy of insurance companies, be denied coverage for pre-existing conditions, including pregnancy, cancer, and a whole host of illnesses, be denied life-saving drugs, or rejected for surgeries, etc.

And among those millions, many will die needlessly because of the greed of the insurance companies and the actions of a Cowboy judge.

What does this mean?

Allow me to put on a different hat here and offer an opinion as to what may transpire in the future, since none of us are clairvoyant. As someone who studied both American history and American government and politics, in my opinion, we will not see universal health care in this country unless and until, to use a medical metaphor, this Conservative/Economic Libertarian virus is eradicated from the American political system, or at least is brought under control.

I do not say this lightly, nor am I being flippant here. Let’s face facts. The Republican Party stands in the way of the adoption of rational, universal health care for all Americans because they are the defenders of a rapacious, greedy Capitalist health care system that demands that investors, shareholders, insurers, manufacturers, and service providers and consultants, be allowed to profit by the health and welfare of the American people.

However, as also reported in the New York Times on Sunday, the ACA could be hard to knock down, despite the judge’s ruling, according to legal scholars quoted in the article.

Yet as Ezra Klein writes in Vox.com, Republicans have refocused Democrats on building what they failed to build in 2010: a universal health care system simple enough and popular enough that it is safe from constant political and legal assault. And that means some version of Medicare-for-all. Democrats are promising swift action once they take over the House in a few weeks, so we wait and see how that will turn out.

But on the other hand, as I have pointed out in previous posts, both those penned by myself, and those that I reposted from other sources, the medical-industrial complex is pushing back hard against any move to alter this broken system.

Two recent posts, Healthcare Lobbying Group Double-Crossing Democratic Voters and Establishment looks to crush liberals on Medicare for All – POLITICO highlights the attempt by the health care industry to keep the status quo, or at least to convince Democratic politicians who might be opposed to full single payer health care, to offer alternatives that will allow the insurance companies to profit from providing coverage to only those who are not sick, which is called adverse selection.

There are some people in this country who argue that what we need is not less competition in health care, but more. However, this misses the point. Whether or not there is more or less competition is not the reason why our health care system is broken. The reason why it is broken is because there is competition in the first place. No other Western country has this problem, and they all have some form of universal, single payer health care.

So, the prognosis for the future of universal health care is cloudy, if not downright gloomy. Advocates for single payer, improved Medicare for All must take a sober hard look at reality and formulate a strategy to meet this new and regrettable challenge. And they must do so with a clear eye and mind on the realities of the political landscape, and not be lulled into thinking that just because polls indicate approval by voters, that enacting Medicare for All will be easy or accomplished quickly. We have enemies, and one of them is Reed O’Connor.

Additional Reading:

Judge Rules Obamacare unconstitutional, endangering coverage for 20 million
Obamacare ruling delivers new shock to health system

 

Comment By Don McCanne

Don McCanne outlines below some things the previous post, Universal healthcare could save America trillions: what’s holding us back? | Opinion | The Guardian left out.

Here are Don’s Comments:

Those who are up to date on the health policy literature may not find much new here, but there are a few points worth emphasizing:

* It is irrefutable that a well designed, single payer Medicare for All program would meet our health reform goals of affordability, universality, equity, effectiveness and efficiency.

* The barrier to reform is not financing since we are already spending enough to pay for such a system, especially once administrative efficiency is factored in.

* Using taxes to pay for the system should not be a problem since our current public spending on government-financed health programs, on tax expenditures for employer-sponsored plans, and on the purchase of health care for public employees would already pay for much of the system, and the remaining taxes needed would be offset by the elimination of insurance premiums, deductibles and other cost sharing.

* The fact that the taxes would be progressive would be a small step to help offset the egregious inequities in income that hold back too many of us who are contributing our fair share of effort to society while too often having to scrimp on essential needs. Tax policies should be used to adjust inequities that result in a select few being able to accumulate obscene levels of wealth – amounts far, far in excess of what their personal efforts contribute to society. They will not suffer from a very modest reduction in their excesses.

* The primary barrier to reform is political. Although Adam Gaffney says, “Good numbers do not a political movement make,” they sure do help. Advocacy is much easier when the facts are on the side of the people. So let’s all get out and nurture that political movement that we need.

The policy fight should be over. It is a political battle that we now face.

Universal healthcare could save America trillions: what’s holding us back? | Opinion | The Guardian

More fuel to the fire on single payer from The Guardian, as a follow-up to my two previous posts on the subject, Healthcare Lobbying Group Double-Crossing Democratic Voters and Establishment looks to crush liberals on Medicare for All – POLITICO.

A slew of studies are confirming that America can afford real universal healthcare, but some call it economically infeasible

Source: Universal healthcare could save America trillions: what’s holding us back? | Opinion | The Guardian