Avoidable Healthcare Act

AHA: As far as mandates go, the Affordable Care Act may be considered far more gentle, reasonable & well-meaning than, say, the Vietnam War era draft. Oh, so you want to require me to have some kind of health insurance, since society may otherwise have to pick up the tab for the minimal care it would be more or less obligated to provide in a pinch. (Emergency vehicles & response personnel are standing by.)

Let’s face it. Some degree of healthcare is a matter of the society, including much physical & staffing infrastructure, research, etc. Like roads, the individual’s active role ends where the driveway turns into the street. The driveway needs the street. In the case of individual health, it’s an inherently mixed equation between what individual & social responsibilities. One without the other leaves everyone more vulnerable. You can be the most health-conscious person alive & still breathe air-in-common with others, & subject to every more or less randomly occurring acute health care emergency.

Facilities & systems are more or less held in common, although a variety of payment systems overlap. Nevertheless, we can’t pick-&-choose only the capacities we expect to need, partly because we may end up needing the unexpected, & partly because most health care issues end up having large numbers put at risk. For reasons others have described in detail, it’s not particularly subject to free market forces.

Even without a driving license, every citizen, every resident, has some responsibility for the infrastructures that make modern life possible–roads, power-grid, schools among them. Costs of the healthcare system at large is clearly among these. It makes as much sense now, with everything cost-per-service correlated, as having every block in a street grid toll-boothed; never mind the cost added by having the driver needing to calculate the costs of different routes as tolls change (if disclosed at all). Now do it in a medical emergency.

A society provides its constituents certain benefits of mutual membership. It’s not a one-sided arrangement. You don’t get to enjoy the benefits of society without also having a fair share of the responsibilities, including a share of the costs. What percentage of transportation-infrastructure costs should be paid by high-usage corporate entities and/or by other various user-groups may be a matter of some discussion, but the principle is clear. Nor is actual current use the key question, where it’s the over-all capacity provided by society at large to itself that matters: roads, rails, ports, medical facilities….

Still, phrasing the responsibility of an adult to the healthcare system as a whole as a “mandate” gave it a strange twist, albeit one with clear Republican roots (Romney’s system in Massachusetts), as a way of universalizing coverage without having the government take over the whole system. It was a worthy attempt to finesse the gap between social responsibility & a system private (insurance) providers.

Many Democrats would feel more at home with a single-payer, government-managed system as a way of universalizing coverage on the basis of social responsibility without imposing a mandate. And then there’s a “pragmatic center” that accepts the social responsibility all have for coverage in the system as a whole, but which would allow roles for both private & governmental coverage providers in what is inherently a mixed system.

It’s mixed from the beginning. Illness is not simply an individual matter, as infectious disease, emergency response, and agencies of public safety make clear. The community has a vested interest in all such matters. Use of public roads may fairly require various kinds of dues, fees, taxes, and coverage, therefore. The same principle may be extended to off-road emergencies & coverage.

Indeed, against some historical resistance, a minimal degree of coverage has been provided for all “senior citizens.” A patchwork of clinics, public health agencies, and other community resources has developed in response to perceived needs. Nevertheless, the need to address significant gaps in the system had become clear enough for the Democrats to pass the partly Republican (in theory, not in actual political buy-in) ACA, believing it an incremental improvement, despite its imperfections.

On the one hand, the whole topic takes on a mind-boggling complexity of moving parts. On the other hand, the central issue isn’t complicated by details down in the weeds. It’s how does the country/society/community reconcile public & private elements & functions. Any satisfactory solution must start by acknowledging the validity of both public & private elements. One must also recognize that these aren’t neatly separated. The most private of enterprises (e.g., pharmaceutical companies) depend on government oversight, as well as other goods & services. The most public of functions (e.g., emergency response) may also depend to some degree on private contractors & products.

Public safety, a primary function of government, requires “responsible community management” of its mixed system–from its roads & emergency response capacity to its community protections, including courts as backstops. Of all community services, healthcare may be considered most basic of all, on the one hand the most intimate & personal; on the other a community matter since the time when that meant no more than family, band or locality, yet a sense deeply embedded in the profession of medicine.

Obama’s effort took the view that it was less critical exactly how the public-private functions were divided than that the community improve the level (extent of accessibility), quality & effectiveness. It started with level or extent of coverage. Effectiveness involved costs, and how paid for. Quality must always be a major part of the concern in measuring the other two, since you haven’t necessarily improved things by providing (or paying for) bad treatment, at whatever price. Even so, in comparison with extent of accessibility, these can be elusive goals, moving targets–how to deliver the best service to the most with the least waste….

Things weren’t improved by the politically motivated attempt to muddy “Obamacare,” which remains far less popular today than the “Affordable Care Act,” though they’re the same thing. The philosophical challenge that might have derailed the ACA in the Supreme Court was the mandate, whether the federal government had the right to require citizens who could afford it to buy a private product (insurance), imposing a penalty otherwise. This was settled by the Chief Justice siding with the Act by declaring the penalties & subsidies tax matters….

It’s a bit strange–not so much how healthcare coverage become a tax matter as how the tax consequences can end up wagging the healthcare dog. The 2017 House Bill, for example, wouldn’t just lead to 25 million or so more people uninsured, but transfer the 800 billion dollars saved into a tax break for a small percentage of the wealthiest. In one state, it was calculated, over 700,000 medicaid recipients would lose coverage, a cost-transfer  going to 400 tax-payers at the top, who need financial help least.

By masking the argument in complexity, the majority of would-be “repeal-&-replacers” don’t actually acknowledge their position comes down to rejecting the social responsibility argument. On the one hand, by treating access to services as if it were purely a privately negotiated matter with minimal government role, the self-described conservatives avoid the issue of social benefits-&-responsibilities entirely, when in fact it’s like putting roads in private hands with unregulated toll booths, & saying that only those selectively covered (who can afford buy-in, for example) can have access to the infrastructure.

In the case of healthcare, it’s a ridiculous argument. Better to address the real questions, like what level of system do we as a society want to provide? how is it paid for? how can it be improved? If may note that I’m personally at an age when I personally prefer the Avoidable Healthcare Act, which comes with a full supply of placebo-based miracle drugs & laugh therapy emergency services, but I would not presume to self-prescribe for others.

As Hippocrates the Hypocrite’s doctor used to say, “One person’s placebo, another’s poison–take your pick, & pickle.” Nevertheless, I pay taxes, medicare dues, retirement insurance premiums covering all kinds of things I’d sooner die from than from the toll the healthcare system would take trying to help. Still, I’m glad the system’s there, & happy enough to pay my fair share to facilities I no longer expect to use. These don’t have to save your life–or the life of someone you care for–more than once to have been worth the contribution….

–March 8/ July 6, 2017