On March 7, Congressman Paul Ryan, speaker of the House of Representatives, called repealing and replacing the Affordable Care Act an “act of mercy.” The next day Representative Joe Kennedy III of Massachusetts countered by calling it not mercy, but an “act of malice.” Delightful as such made-for-cable sound bites are, their true value lies not in their drama but their capacity to remind us that there are profound moral dimensions to how we structure health care in this country.
Petty politics can sometimes numb us to this fact, however; so can the complex nature of policy itself. But giving in to either means becoming numb to real people: to our uncle battling cancer, to our cousin with developmental disabilities, to our parents in need of skilled nursing care. We lose our way when we forget that it is the policy details that end up affecting real lives—and ultimately affect who we are as a people.
In order for this debate to move beyond who can score the most political points, we have to do some digging. And the first thing we will find when we start digging is that our current health care system is not just one system. It is many systems, conflicting and overlapping. And this means that—despite the clarity of words like mercy and malice—the real reason our debate about health care reform is so muddled is that we are actually debating the reform of several systems cobbled together over time and based on very different philosophies.
Reforming our health care system is like trying to fix a home where each room not only has a different architectural style but is built on a different foundation and has its own HVAC system. It is the kind of renovation that would make most contractors throw up their hands and walk away. But since we are all living in this house, we had better figure out how to renovate it.
Too many programs
Health has a great deal of uncertainty. While there is some predictability based on risk factors, we never know when we will be diagnosed with depression or diabetes; we do not know when we will be in a car accident. Pooling people together shares both the risks and the costs of health care. The people who are fortunate enough to stay healthy end up subsidizing those who get sick; and the ones who get sick do not have to bear the full cost of their care. Shared risk is how all insurance works—it is why we do not begrudge the person whose home catches on fire a large payout.
Our current U.S. health care system pools people in many different ways. In addition to Medicare, there are over 50 separate Medicaid programs, thousands of employer plans, health co-ops, the Children’s Health Insurance Program, the Veterans Health Administration and the Indian Health Service. Some say the core problem is the administrative chaos that comes with running so many separate systems. I believe the core problem is that we do not have a shared understanding of the role of health and health care in our society. And all these separate programs are evidence of it.
Is health care a social good or a market good?
It is obvious why insurance companies would want to keep some people, like those with pre-existing conditions, from jumping into a risk pool. Such an approach might be good for business, but it means those most in need of care go without it. To prevent this, the A.C.A. mandated two things: No one can be denied access to a risk pool because of their health status, and those with serious disease cannot be charged more for their insurance.
Creating larger risk pools and guaranteeing more people access to them were not just technical changes to the system. They changed some of the basic assumptions we as Americans make about health and health care. They shifted the foundations upon which our systems are built. And now Republicans are trying to figure out how to renovate a house when we do not even know where the foundation is. So before we take any further action, perhaps we should step back and ask what we actually believe.
Lex credendi, Lex vivendi
When we decide to act, we can either design a system that treats health care as a social good or as a market good. Whether we think of it as one or the other determines our answers to a whole series of questions. Should health care be guaranteed for everyone? Should the government have a role in ensuring access to care? Or should market forces decide how care is distributed? And should for-profit companies play a central role in care?
Those on the political left tend to push policy rooted in health care as a social good, while those on the political right tend to push policy rooted in health care as a market good. But that is not what we have with the A.C.A., which is what makes both the A.C.A. and today’s Republican efforts at repeal so terribly confusing.
The Affordable Care Act has changed our expectations. It shifted the way we live, which may be shifting what we believe.
In the A.C.A., we essentially have a progressive agenda on a conservative scaffold. A quick look at the modern history of efforts to reform health care shows us why this is true. The Health Security Act promoted by President Bill Clinton in 1993 relied heavily on government bureaucracy to achieve universal coverage—regional alliances to negotiate with insurance companies, a national health board and a strong mandate for employers and individuals. After the effort failed, Democratic strategy was to avoid accusations of government overreach and to adopt many of the ideas advocated by the conservative Heritage Foundation. Essentially, Democrats felt that they only way they could deliver health reform was with a Trojan horse.
Does this mean that Democrats suddenly believed health care was a market good? Hardly. It means that the Democrats were politicians. They endured private marketplaces while expanding Medicaid and regulating insurance companies. This tempered the critique that it was antimarket while delivering wins for health as a social good. And in short order, they have shifted the assumptions we Americans make about health care. Before the A.C.A., we had not lived in a country where people with pre-existing conditions had access to affordable insurance. We had not experienced what it meant for the sick to avoid lifetime benefit caps. And we had not seen that it was possible for the working poor to receive affordable care. But the A.C.A. has changed our expectations. It shifted the way we live, which may be shifting what we believe.
This is why Republicans are faced with quite a conundrum in their efforts to repeal and replace the A.C.A. President Trump regularly promises universal access to high quality care with low premiums and low deductibles. But that is the rhetoric of someone who believes that health care is a social good. Many Congressional Republicans also suggest they wish to keep many guarantees of the A.C.A. that are made possible only by anti-market provisions or huge government subsidies. But conservative philosophy still holds that health care is a market good. So what is their way forward?
The Republican-controlled House passed a bill on May 4 that allows states to opt out of many regulations: pre-existing condition protections, lifetime and annual cap prohibitions and essential health benefits. This would allow states that want a more market-oriented approach to move in that direction. The bill also gives states more control over Medicaid but cuts federal contributions by $880 billion. It lacks credibility to claim such cuts would not prove devastating to the poor, disabled and elderly. In fact, Speaker Paul Ryan also has his eyes on moving Medicare from a defined benefit to a defined contribution, although he could not include that in this legislation.
There is no way to make health care more market oriented and keep the protections people now enjoy.
The Senate now takes up health care reform. They may find a way to thread the needle politically, but in the end, Republicans are trying to replace a health care system that is already built on a conservative framework. There is no way to make it more market oriented and keep the protections people now enjoy. This is why it is so difficult for them to agree on why they should repeal it or on what they should replace it with.
John Kasich, the governor of Ohio, was one of many Republican governors to expand Medicaid as part of the A.C.A. Explaining his decision in February 2013, he said he was unwilling to turn his back on "those who live in the shadows of life...those who live with the least among us." He urged lawmakers to put themselves in the shoes of a poor family who cannot afford health care or parents dealing with a mentally ill child: “Put it in your family. Put it on your doorstep.” It is easy to believe that health care is a market good until tragedy strikes someone we love. Then all of a sudden, market forces do not seem as reliable as we would like.
Health and Hazards
Catholic social tradition is aligned with the idea of sharing risk and ensuring that the sick have access to care. During the debate on the A.C.A., Bishop William Murphy, then the chair of the U.S. bishops’ Committee on Domestic Justice and Human Development, wrote,“Reform efforts must begin with the principle that decent health care is not a privilege, but a right and a requirement to protect the life and dignity of every person…. The Bishops’ Conference believes health care reform should be truly universal and it should be genuinely affordable” (italics in original). Unsurprisingly, Pope Francis concurs that health care is a universal right and not a consumer good. This consensus among church leaders, however, does not mean that skeptics of universal health care do not have legitimate concerns.
One of the biggest such concerns is called “moral hazard.” This is the idea that people who are shielded from the consequences of their action are more likely to take inappropriate risks. In health care, the concern is that those who do not pay for health care will be less likely to stay healthy or will opt for unnecessary medical procedures. This worry leads many to ask, “Why should I be paying for someone who smokes, eats whatever they want and refuses to talk a walk?”
The concern for moral hazard is a real one; after all, our Catholic social tradition embraces not only universal care, but personal responsibility. Yet this critique must be held in tension with the notion that many of the behaviors we believe are “chosen” are determined strongly by our environment. We know it is wrong to punish children for unhealthy behaviors because we accept that children are shaped by forces outside their control. But for some reason we pretend adults are magically immune from these forces. Think of it like this: How many of us can say that we could eat in a healthy way while working two minimum-wage jobs and raising a child, all while having to ride two separate buses to get to the grocery store? How many of us would make it to all our medical appointments if we lived a 60-minute drive away, had to borrow a car to get there and had to miss work (paid by the hour) to do it? It may be true that adults have greater control over themselves and their environments than children do—but it is often far less control than we imagine.
I think most of us actually hold nuanced beliefs on these matters. We want to care for people, but we do not want to be taken for suckers. We recognize some people have disadvantages, but we want people to take responsibility for their health. There is no perfect solution to this dilemma. We will not get it exactly right. And it is because we will make mistakes here—mistakes that may cost people their lives—that we have to face an important question: Which way do we want to err? Do we risk being too merciful or too judgmental? Would we rather risk giving care to those who are sick even though they could have avoided illness, or risk denying care to those who are sick even though they could not escape it?
A Risky Conversation
Some politicians continue to claim we can have the most popular provisions of the A.C.A. without having the unpopular ones. They are wrong. And if that belief comes from ignorance, it can be corrected. The more deadly deception is from those who claim they want a compassionate society while advancing a system that leaves the most vulnerable without the care they need. It is common political practice to promise we can have the upside without bearing any of the downside. But when we build a health system on that falsehood, people die. A civil rights leader from Mississippi once said, “Don’t tell me what you believe. Show me what you do, and I will tell you what you believe.” If we want to claim the virtues of solidarity, generosity and compassion, we must live with both the benefits and the costs of designing a health care system that responds to those in greatest need. Otherwise, we will have to admit a brutal truth, that we do not really want to sacrifice for our neighbor, and we will live with a health care system that assesses whether someone is worthy to receive care.
Legislators who want to repair, replace or repeal the A.C.A. will have to reckon with the fact that a growing number of Americans want a system built on the foundation that health care is a social good. Many may hesitate to use that language, but the overwhelming support for antimarket provisions in the A.C.A. speaks for itself. If Democrats are interested in moving their own agenda forward, they will have to make an argument based on first-order principles rather than second-order policies. A Trojan horse only works once, so Democrats will ultimately have to persuade the public on more fundamental ideas of sacrifice and solidarity.
Most ardent supporters of the A.C.A. admit it needs repairs. And many vocal critics admit the financial protections and guarantees to access provided by the A.C.A. make our system better than it was before. Given that health care makes up nearly a fifth of our economy, this debate will always be near the center of social policy. But we cannot keep pretending that fundamental beliefs about what we owe to one another do not matter. This conversation is, admittedly, a risky endeavor. But it is a risk we ought to share with one another.