Tuesday, July 17, 2012

Giving the Affordable Care Act ("Obamacare") a Human Face

My friend Tracy (a wonderful actress and church secretary) has an infectious laugh, a somewhat racy sense of humor, and a daughter with juvenile arthritis. Shortly after the Supreme Court upheld the constitutionality of the Affordable Care Act, Tracy's family posted the following image of their daughter (along with the accompanying text) on Facebook:

The image went kind of viral. Earlier today, Addicting Info posted an article about Cassie, "The Face of Obamacare." The details of Cassie's story appear there.

I haven't said much about health care reform on this blog, in part because it is a complex topic about which I have little in the way of what might be called expertise. But here are a few things that seem pretty clear to me:

1. The most controversial aspect of the ACA is the so-called "mandate"--that is, the requirement that all Americans have a health insurance policy or pay a fine. This is the part of the ACA that Justice Roberts declared a tax. I think this is a fine way to look at it, even if Obama resisted calling it a tax for political reasons.

2. The mandate is an essential trade-off for the part of the ACA that most directly affects Cassie and her family--namely, the clause that precludes insurers from denying coverage based on pre-existing conditions. Were there no pre-existing conditions clause and no mandate, there'd be nothing keeping healthy individuals from just going without insurance until they get sick. So, we need one or the other: either there has to be some requirement that everyone have insurance if they can afford it (parts of the ACA are directed towards addressing those who can't afford it), or insurers will deny coverage for pre-existing conditions. Either the liberty of individuals to risk themselves in order to save some money has to be truncated, or the opportunity of people to get the coverage they need will inevitably be denied them. To have it both ways--unrestricted individual liberty to take risks and opportunity for the neediest to have their needs met--just isn't a realistic option. We have to choose. The question is whether we choose the liberty of all to risk going without health insurance or the liberty of all to get the health insurance they need.

3. If we favor the former, there are people who are going to suffer--people like Cassie. And her parents. And her siblings and all the others who love her. I don't like that result. I think about the fact that Cassie could easily have been one of my children. I think about the fact that Cassie is, in fact, the child of people I care about.

4. Also, if we favor the former our ERs will be filled to the gills with the uninsured who go there for all their medical needs when they become urgent enough (and hence are, more often than not, costlier than they might otherwise have been). This leads to increased medical costs for the rest of us--since the costs of treating the uninsured have to be recovered somehow. Viewed in this light, the health care mandate can be seen as a way to guarantee that everyone who can afford it does their share to pay for health care, rather than there being "free riders" that the rest of us end up paying for.

5. Favoring the former is routinely represented by ACA opponents as government tyranny because it is making demands on people, requiring that they buy something. The implication seems to be that favoring the latter respects liberty in a way that favoring the former does not. But as Cassie's story makes clear, her family faced serious truncations of liberty--imposed not by the government but by private insurance companies; companies who, out of an interest in maximizing profits, uniformly exercised their freedom to deny coverage such that Cassie's parents were denied the freedom to buy for their daughter what she so urgently needed.

6. What we have here is a choice about whose liberty is more important: the liberty of the healthy 30-something to risk going without insurance, to gamble that he won't get sick (a gamble that the rest of us pay for when he shows up at the ER with an infection that has gotten out of a control and takes expensive life-saving measures to cure); or the liberty of people like Cassie's parents to provide for their children the things that those children need in a way that doesn't bankrupt them.

7. What we have here is a choice between who is going to impose constraints on our freedom: the government, which is made up of elected representatives who are ultimately answerable to the public and are voted into office with a mandate to pursue the public good; or private companies, which exist to make profit and are answerable primarily to those for whom they are making that profit (e.g., stockholders).

I'm sure there are lots of problems with the ACA. It is a clunky and complicated piece of legislation aimed at trying to achieve what, it seems to me, could be far more elegantly achieved by moving to a system in which Medicare is extended to provide universal basic coverage paid for through taxation, and supplemental coverage is available through private insurers. Yes, there are surely problems with the ACA. But favoring a health insurance mandate for those who can afford it over a system in which people like Cassie find themselves unable to get insurance because of pre-existing conditions? That doesn't strike me as a problem with the ACA. That strikes me as one of its virtues.

1 comment:

  1. Have been reading through your posts since I was directed to your post on Patriarchy. You are thoughtful and well-spoken. I have now adopted 'progressive Christian' as my title, I never really liked 'Evangelical' anyway:) Will continue to read your posts.