President Trump continues to threaten millions of Americans who now have health insurance with loss of coverage by undermining the Affordable Care Act, commonly known as “Obamacare.” His goal has been to repeal the ACA, or to have it repealed by a version of congressional bills.
A July 28 vote killed the Senate bill temporarily, but the threat to those with coverage through the ACA is not over.
As we await the next proposals and rounds of debates, now is a good time to reflect on what the Republicans most detested about Obamacare – the individual mandate, which they argued took away personal choice. The mandate was an essential part of the law, however, by guaranteeing insurers that they would have a large enough pool of healthy people to offset the costs of insuring large numbers of unhealthy people.
As a philosopher of health policy, I think it could be instructional to assess their recent proposals through their lens of “choice.”
Universal access and choice
The public debate on proposed health care laws has focused largely on the number of uninsured, which would be lower if we moved to universal coverage. Many experts, advocates and nonprofit research groups, such as Kaiser Family Foundation, use the proportion of people who are covered as a quick way to test whether people have real access to health care. We got partway there with the ACA, with the percentage of uninsured dropping to 9 percent in 2015.
After Trump was elected, Republicans tried to come up with bills, however, that focused not on reducing the number of uninsured but on ensuring that people had a choice about whether to buy insurance. They fought the mandate from the law’s beginnings, filing a lawsuit that reached the U.S. Supreme Court. Chief Justice John Roberts, a George W. Bush appointee, wrote the majority opinion that the mandate did not violate the commerce clause of the Constitution.
If we take them at their word, the system the Republicans aim to replace the ACA with should be focused more on the choices people have, not the number of people who gain insurance.
The public should take seriously, at least for the sake of argument, the words of Paul Ryan, when he said that no one should have to do something they do not want to do. “Our plan is not about forcing people to buy expensive, one-size-fits-all coverage. It is about giving people more choices and better access to a plan they want and can afford,” Ryan said in a statement issued in March 2017.
Their intent is to replace the goal of universal coverage with an alternative which some have called “universal access.” Universal access aims to give people the “choice” of having coverage or foregoing that coverage for other priorities they may have.
What would a real choice require?
To have a real choice, people would have to be able to buy insurance plans that meet their possible health needs, both for prevention and treatment. They could compare that choice with the choice to forego coverage.
This means they are not in the position of having only a forced choice. If they have a real choice, they no longer are choosing between a plan they can afford, whose reduced cost reflects the fact that it fails to provide access to preventive or treatment services they want and need, and one they cannot afford at all, though it provides access to the preventive and treatment needs they come to have.
Millions in the U.S. faced such a forced “choice” when they bought in the individual health insurance that preceded the ACA marketplaces.
Such a choice is not a real choice. It is forced because the outcome is determined by limited resources and the lack of freedom that the situation creates.
Paying for real choice
Of course, since some goods we want, like cars, come in different brands with different prices, we may not see buying a Chevy instead of a Mercedes as a loss of freedom. If we only want a way to get from A to B, we might not care that the Mercedes provides a better ride and is more prestigious.
But, in buying access to health care, we all want the best care. We all, correctly, think that we are valuable in the ways that health care systems should respect even if we have other preferences and priorities regarding cars. In short, people generally accept ability to pay as a principle for car purchases, but not as a principle for buying access to needed health care.
Accordingly, the Republican effort to avoid coercion and take choice seriously would cost more than their plans allow.
The plans they have offered significantly reduce subsidies to the poor and throw people out of Medicaid, resulting in an estimated 22 million people losing insurance coverage. The result is a forced choice, not a real choice, especially for people who want some coverage and perhaps need it but have limited resources that would have qualified them for Medicare or subsidies.
What happens when some people ‘choose’ to forego coverage?
The Republican approach does not seem to take into account that even a real choice to forego coverage imposes harms on third parties. It does so by raising the cost and thus limiting the availability of insurance to other people.
Since the Republican plans purport to care about the choices for everyone, these consequences – the harms they impose – are ethical reasons to oppose them on their own terms. Young, healthy people should not be able to “choose” to forego coverage when older, sicker people face only forced choices.
Many people want coverage. What happens to the costs of insurance if the system allows people, who save money by foregoing coverage while they are young and healthier than the average older, sicker person, to receive needed emergency care when they need it?
Consider “free riders,” who may be anyone who foregoes buying insurance coverage but later can get needed health care. The cost of a system that allows people to join it when they have not shared in the cost of providing that care is greater than the cost of a system that excludes such “free riders.”
So allowing those who free ride not to die in the streets when they need care, which is what the existing system of emergency medical care (EMTALA) intends and which Republican plans do not challenge, means that free riding imposes higher costs on those who buy insurance coverage. This is a harm to those who have a real choice to buy coverage. This harm to others involves a cost that goes beyond the unfairness of allowing those who do not contribute their fair share to enjoy the benefit of health care when they need it.
Creating this incentive to free ride is part of what creating “choice” – as envisioned by Republicans – involves.
Similarly, the Cruz amendment, proposed by Sen. Ted Cruz (R-Texas), to the recent Senate bill would have allowed insurers to market less expensive plans that skimp on needed health care as long as the insurer also markets less skimpy plans at higher prices.
But the increasing stratification that this amendment produces means greater costs to those who buy less skimpy insurance, harming them. (At the same time, those people facing a forced choice of the skimpy insurance or less skimpy but unaffordable insurance are said to simply “choose” it.)
In sum, the “choice” underlying the congressional plans not only is not really paid for, but exercising that “choice” would harm others in a way that undercuts any appeal it has. Universal access is worse than universal coverage because of the “choice” it creates.
Brendan Saloner, assistant professor at the Bloomberg School of Public Health at Johns Hopkins University and a former student of Prof. Daniels, contributed to research for this article.