Since the question of the implementation of the Affordable Care Act has been getting media attention recently--especially after Max Baucus's statement from a few weeks ago, I thought I would turn some past musings and jottings of mine into a diary on health care and the ACA. The Patient Protection and Affordable Care Act, albeit imperfect, was an improvement on the status quo. In this diary, I want to do two things: (1) analyze the framing and justification of the individual mandate and (2) discuss the role of public and private in a health care system from a normative perspective.
I began thinking about the mandate again after reading an article on the Affordable Care Act from the Roosevelt Institute's Next New Deal blog last month. The author looked at how low-wage workers, such as fast food workers, may fare poorly under the ACA's provisions because the deductibles of their new employer-provided health care will be more expensive than the penalty for no coverage. As the full scale of Affordable Care Act unfurls, we'll get to see more about how well it accomplishes the goals implicit in its name. Hopefully, it will.
However, the case above underscores the counter-intuitive contours of the debate around the individual mandate. The individual mandate is a conservative policy that can only be championed through conservative rhetoric. Befitting a conservative policy--especially one originating at the Heritage Foundation--it penalizes those on the lower end of the income scale for being on the lower end of the income scale. No one actively does not want to have health insurance; the uninsured are those whose job will not cover their insurance or who simply cannot afford to purchase insurance on their own.
Arguing for the individual mandate requires a rhetoric of "individual responsibility," a frame that makes use of the image of "freeloaders" who take advantage of mandatory hospital care (a policy from Reagan). These "freeloaders" who are "shirking" their personal responsibility sound a lot like the "moochers" of the right-wing imagination. The language that supports the individual mandate counters the (liberal) idea that health care is a fundamental human right.
If viewed as a tax instead, it is regressive, and it taxes people while not directly providing services. In a single payer system like Canada's or a multi-payer system like Germany's, individuals are taxed to pay for their health insurance. However, those who would be taxed under this system are not benefiting in such regard.
I know I've used the car insurance analogy to justify the individual mandate on legal grounds in discussions before, but the analogy is rather weak. You can choose not to have a car, and you can choose to sell your car if you want. A health insurance mandate applies to your very person.
A more appropriate comparison would be the other main mandate that we have for the individual as individual: our education mandate. In the U.S., we have compulsory attendance for primary and secondary school, and each state has a similar requirement, mandating a certain minimum number of years of attendance. These laws arose at the state level (rather than the federal level like the ACA), but the mandate that they contain is attached to the individual, not to a physical object the individual can choose to own.
I have always thought that education and health were both similar because of their integral role in the concept of the public welfare. Unlike what many on the right would like to believe, the Constitution does assert the government's role in promoting the "general Welfare." It also asserts the government's role in securing "the Blessings of Liberty." Here, I think, it would be important to underscore the role of education and health care to the concept of positive liberty. Conservatives often speak in terms of negative liberty, freedom from external restraint (at least, when it doesn't come to reproductive issues, for one). However, positive liberty--the possession of the power and resources to fulfill one's potential--is essential to liberalism. The Standford Encyclopedia of Philosophy explains positive liberty in the following way:
Put in the simplest terms, one might say that a democratic society is a free society because it is a self-determined society, and that a member of that society is free to the extent that he or she participates in its democratic process. But there are also individualist applications of the concept of positive freedom. For example, it is sometimes said that a government should aim actively to create the conditions necessary for individuals to be self-sufficient or to achieve self-realization
Education and health care---the culture of the mind and the health of the body--enable individuals to be engaged citizens and to pursue meaningful work; they provide the conditions necessary for individuals to realize their potential.
Returning to the prior discussion of mandates, you might note that there is a key difference in how we implement education and health care policy. With education, there is a clear mandate, but the government finances and administers schools to help people to comply. The government says, "You must attend school from age x to age y, and we will make schools available for you to do so. You can opt for private school if you wish--on your own money, but we will make sure that you have a solid option paid for and administered by the collective purse."
But if the education mandate were like the health care mandate, the government would run no schools. The government would be the single payer of pre-K or kindergarten (an equivalent for Medicare here). The government would pay your full school costs (or most of them, at least) if you fall below a certain income. If you make more than that and don't already send your children to school, the government might organize you and other parents in a pool for greater efficiency and give you some start-up capital and subsidies. The government would make sure that the schools that exist cannot deny students because of learning disabilities or any other issues. However, the government would run no schools.
Now, to reverse that comparison, how would the health care system look if we designed it based on the principles by which we have designed the education system? First of all, everyone would have a publicly-administered and publicy-financed primary care practice in his or her neighborhood. You would have to register with your local practice. If you choose not to enroll there, you still have the option of going to a private practice (a mandate of coverage would hold), but the government will not pay for you to do so; it is your own choice. Primary care is something that everyone needs, and the local demand for primary care is in direct correlation with population.
However, what about hospitals and the various specialists that reside there? A comparison to higher ed works to some degree here. Each locality would certainly need access to a hospital with various specialists; however, the demand is not as directly tied to population as the demand for primary care is. It might not be advisable for the number of each type of specialist to be determined by a centralized agency. Consequently, you would have less of a public monopoly but still a strong public presence in the market. The state would administer and finance a number of hospitals, employing a number of different specialists, to ensure broad access; however, many would exist in the private sector as well. The state-administered hospitals might not have the most expensive technologies or snazzy interior design; however, they will offer a robust array of services.
However, with the rising costs of higher ed and growing student debt (like health care debt), our current financing arrangement is certainly not perfect, and the comparison I've drawn would need to be further worked out and perfected. Perhaps the state would pay for the full costs at the universally accessible institutions that it administers and would subsidize the costs of individuals who choose to go to the private hospitals (paying only to the level of cost of the public hospitals). We would also need to have the efforts of cost-control so badly needed in higher ed right now.
I want to transition now to a more direct discussion of the role of public and private in health care, especially on normative grounds.
If you haven't already read Steven Brill's compelling, depressing, and long article in TIME (from a few months ago) on the U.S. health care system and how providers take advantage of consumers in this grossly unbalanced marketplace, you should. (Let me tell you a joke: perfect information.) The article reminded me of an argument that I have made in the past---which often takes the form of a rant--about why health insurance does not belong in the private sector.
Now, if we are determining whether an industry belongs in the public or the private sector, we can debate on two planes: that of facts and that of morals. In a past diary, in which I railed against the empty mantra of "common sense," I affirmed that all policy-making arises from an interplay of facts (data) and morals (priorities). In the discussion of public vs. private industries and goods, the central point of the first debate is the question of efficiency, and the central point of the latter debate is the question of choice.
My discussion will continue under the assumption that universal health care is a universal and worthwhile goal, as I discussed in the section above. Unfortunately in U.S. politics, that often seems not to be the case. However, for a democracy to function well, its citizens must be healthy of both mind and body. The former requires attention to public education, the latter to public health. A democracy that does not guarantee universal education and universal health care is a democracy in name only.
Defenders of the market often claim that privately-run organizations are more efficient than their publicly-run counterparts, and if we are going to determine whether an industry should be publicly-run or privately-run, then we should ask under which control the industry is most efficient.
Total health expenditure per capita in the U.S. ($8,233) is over twice the average of the countries in the OECD ($3,268). Various procedures also cost significantly more than they do in other industrialized countries. Despite such spending, the life expectancy at birth in the U.S. is still lower than the OECD average, the number of physicians per person is low, and the rates of asthma hospitalization and obesity are high. We are spending a lot of money on health care but are not getting our money's worth.
Looking within the United States itself, Medicare is more efficient than private health insurance for reasons such as its greater bargaining power and its reduced costs in administration and marketing. The executive administrator of Medicare also won't be making $7.3 million.
Efficiency is, for the most part, a question of empirical data, rather than of ethics. When we discuss health insurance and ethics, conservatives tend to bring up the issues of individual responsibility and, perhaps more heavily, choice.
Goods that resolutely belong in the private sector are those for which choice matters--that are a function of individual taste or desire or which facilitate individual self-expression. Fashion, restaurants, and cinema all come to mind as immediate examples of industries that cater to individual tastes, and clothing in particular facilitates individual self-expression. In such categories, the difference in people's preferences are qualitative above all: they are not mere functions of price. (Within any given price range, there will be a lateral diversity in quality and character.)
Now, choosing between health insurer A and health insurer B is not a matter of individual taste or self-expression. Health insurance is much more of a need than a desire, especially if we assume (as we do here) that all should be insured. One's need, however, is not dependent on one's ability-to-pay. You do not need less coverage because you make a lower income. Choice, in this case, means "you get only what you can afford, no more" whether or not it meets your needs. No one wants to have less health coverage. Price constraints are the motivating factor in the selection of such options. Likewise, the lateral diversity at each price level such as that which exists in restaurants and fashion does not apply. In such a situation, choice lacks the moral quality that it has in the situations noted above; it does not facilitate individuality, but rather reflects and exacerbates poverty and inequality.
In cases like this in which everyone's needs are the same although their ultimate "choice" depends solely on their ability-to-pay, the state should provide the service in order to guarantee the highest level of service to all of its citizens and to provide the security needed to enable the free play of initiative and enterprise in other sectors.