The Supreme Issue? Health Care Reform

President Obama's signature approving the health insurance reform bill

It’s not the economy, stupid.  I know most of the pundits say that the November election will pivot on the state of the economy.  But their I-can-only-see-the-story-right-in-front-of-me groupthink forgets what is coming this summer.  The dominant issue of the 2012 election will be: health care reform.

I realize you are thinking “Come on, Rozier, health care reform is so 2010”.  Just hear me out ye of little patience.

This summer the Supreme Court of the United States will hear a case challenging the Patient Protection and Affordable Care Act of 2010 (popularly known as Obamacare).  The many lawsuits that have twisted their way through our court system have hinged on one central aspect of the new law – the mandate that individuals must purchase health insurance.  It will become the story of the summer regardless of the courts decision; it will become a central part of the campaigns for both parties.  Sadly, so few of the people asking for your vote have any idea of what they are talking about.  Even more sadly, you will hear it framed exclusively as an ideological issue – tea party liberty versus socialist welfare state – when, at its core, health care is a moral issue.

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In the fifth chapter of Luke, Jesus proclaimed, “It is not those who are well who need a physician, but those who are sick” (5:31). It seems obvious.  Who would send a physician to someone who is well rather than someone who is sick?  Truth is: we do.

From the time Obama campaigned on health care reform to March of 2010, we in the United States have played political games with people’s lives.  Electoral wrangling and political ideology have driven our national discourse, while the very thing that evidenced the need for reform – the life and death of those who could no longer afford care – was forgotten.  Now with the 2010 law certain to go before the US Supreme Court, we have another chance to get things right.  We Americans are answering a question about who we are with this national health care discussion.  The question is: will we admit it?

In the world we live in health insurance is necessary to gain access to high-quality care, but those with a history of illness – those with pre-existing conditions – are excluded from most health insurance plans.  Before the new law, people with pre-existing conditions were either outright excluded from purchasing health insurance or had premiums so expensive that few could afford it.  Because of such exclusions, those most in need of care were the least likely to receive it and we therefore provided physicians more readily to those who are well than those who are sick.

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Our health care system has operated in ways in direct contradiction to Jesus’ proclamation, but it is evolving.  These are the facts:

  • In September 2010, Obamacare began prohibiting insurance companies from excluding children with pre-existing conditions.  As of 2010 a child with asthma could no longer be disqualified from care.
  • Until January 2014 private insurance will continue to exclude adults with a history of diabetes, cancer, or other health conditions.
  • In the meantime a taxpayer-subsidized high-risk pool has been established to insure such high-risk adults.
  • Over the next six years various provisions of the reform law will be phased in, largely implementing ways to cover the working poor and the very sick.

Even with all this said we voters will likely receive the same confusing media coverage of the law as it gets implemented that we received when it was first being debated in Congress.

One thing voters are not confused on is their moral sensibility, a sensibility that easily sees that excluding the sick from insurance is wrong.  According to a 2009 TIME magazine survey, over 80% of our nation rejects the status quo, preferring instead the requirement that private insurance companies insure people even if they suffer from pre-existing conditions. In my opinion, this moral common ground – that those who are the most sick should have access to care – is the most important element of the health reform law.  This change in the law recognizes a conviction held throughout the developed world, across oceans and party lines, the conviction that everyone should have access to high-quality health care.

But the sad fact is that there is a major problem with our goodness of heart – the problem is that if we force companies to insure everyone who has a pre-existing condition to buy health insurance in all likelihood these companies will go bankrupt.  Imagine the possibility:  I know I can enroll in a health insurance plan at any time, so why would I pay a premium when I am healthy?  I will just wait until I get sick and then I will buy health insurance.  The problem is obvious, and it is the same problem that an insurer would face if they allowed someone to purchase home insurance after their house catches fire.  No company could survive this possibility.  Viewed from this angle we can see that it is not only reasonable but responsible of private insurance to exclude those pre-existing conditions.

So 80% of our nation thinks we should do something that would take down the entire private insurance system.  How can something that feels morally required be impossible to actually do?

Truthfully, and thank God, it is actually not impossible.  The way to maintain the private insurance system and include people with pre-existing conditions is to require everyone – the healthy and the sick – to purchase health insurance if they can afford it.  This is the infamous “individual mandate”.  It’s right here that morality bumps into ideology.   The individual mandate is the controversial element of health reform driving most of the lawsuits challenging the law.  Even though the Constitutionality of the individual mandate is up for debate, it is undeniable why it exists; the individual mandate exists because it is the only way to allow for a private health care system that also supports people with preexisting conditions.  In other words, the most controversial part of the law is inextricably linked to the most desired part of the law.

It presents us with a Solomonic choice; the kind that our nation is not good at admitting must be made.

The wisdom of King Solomon

If we maintain the private insurance system and we believe that people with pre-existing conditions should be given access to health insurance we must also require that people purchase health insurance throughout their lifetime.  If we do not, we face the challenge described above of people purchasing insurance only after they are sick, a challenge which would lead to the collapse of the private health insurance system.

The only other option, which garners very little support in the United States despite its existence in nearly every other high-income country, is a system that minimizes private insurance.

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Many high-income countries feature health systems in which the government takes on the role of insuring everyone and establishing methods of payment.  It is then up to hospitals and physicians in the private sector to be as effective and efficient in delivering care as possible.  Although not perfect, this kind of system does two things: it maintains some market-based supply and demand all while ensuring that everyone has some claim on the supply.  In truth, 68% – you read that right, over two thirds – of US health insurance dollars are already run through Medicare, Medicaid or the Veterans Affairs system.  Americans already use government-based insurance to a great degree.  But it seems that we can’t even bring this up in our current political climate.  The idea of side-lining a private industry, even one that has served us as poorly as the health insurance industry, goes so contrary to the “market=good, government=bad” meme in our country right now that such a plan amounts to ingesting political anthrax.

So what do we take away from all this?  Just remember: as the media reports on the lawsuits over the individual mandate, you will likely only hear half of the story.  Interviewers will ask: “Should people be required to purchase health insurance?”  But my bet is that these same interviewers will not present the real problem; they won’t set up the Catch-22.  We have to remember that no one would suggest a mandate to purchase insurance if it were not absolutely necessary.  The full consequences of one’s answer must be known before giving a response.

Answering such an interviewer by simply saying “people should not be required to purchase health insurance if they don’t want to” makes sense given our American preference for market solutions and individualism.  But eliminating the mandate and keeping a private insurance system means the law will be scrapped.  It means that insurance companies will once again be able to exclude people based on pre-existing conditions.  It means that the goodness of our hearts will have been trumped.

Answering by saying “people should be required to purchase health insurance” acknowledges what every other developed nation has admitted – for the sickest among us to receive care, we must all participate in the system.  The truth is that none of us knows when we might be the one in need of expensive care.  I might be subsidizing someone else’s chemotherapy today, but it takes only the slightest slip for me to be the one on the operating table needing care that I can no longer afford.

Without the individual mandate, the most widely accepted and morally required element of the health reform law disappears.  No country has ever achieved universal health care without some form of mandatory participation.  Media reports on the lawsuits challenging the mandate have thus far ignored the moral implications of the court’s decision.

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So let’s be clear about the Solomonic deal that stands before us: if you believe that people with pre-existing conditions should have access to health insurance, you either believe in the individual mandate or you believe in a nationalized health insurance system.  And it’s all because you simply cannot simultaneously believe in the following three propositions: (1) we should have a private insurance system, (2) should eliminate the individual mandate, and (3) should give people with pre-existing conditions access to care.  The problem is that too many people in our country continue to claim that they believe in all three.   Listen, claiming this might fit the various elements of one’s ideological worldview but it does not fit in the real world.  If we are to move forward with building a better health system in this world, in this United States, then we have to be honest about what is really possible.

For me it’s simple.  I contend that caring for the sick should be the fundamental priority of our health care system.  I believe our national instincts are right – that those who are most vulnerable to illness, those with pre-existing conditions, should have access to health care through our insurance system.  With that as our moral foundation we can build a health care system that rests comfortably on top of it.  What we cannot do is continue to pretend that our moral instincts to care for the sick can remain disconnected from the practical realities of health insurance.  If we as a country follow the road of accepting a private insurance system without an individual mandate, we should not feign surprise when those who are most sick are once again left without physicians to care for them.

Instead, we should be ashamed.