As Republican efforts to repeal the Affordable Care Act ratchet up, two themes repeated over and over must be debunked.
The first extols the virtues of, and exhorts a return to, “free markets” in our approach to health care. The second vilifies the use of “mandates” within the ACA.
Let’s be clear, free markets are never free. What’s really being said is health care should be available (with limited Medicaid exceptions) only to those who can afford it.
The “free market” era that existed before the ACA, and that Republicans would return to, left 50 million people uninsured. These people, when confronted with a health emergency, went to hospital emergency rooms (the highest cost component in our health-care system), where their immediate needs were met and they were discharged – until their next health emergency.
Is this “free-market” efficiency we should return to?
Many millions more (even if they had some form of catastrophic health-care coverage) lacked access to routine, illness-preventing health care; they were an illness or job layoff away from bankruptcy. Pre-ACA data indicates that nearly half of all personal bankruptcies were attributed to illness-related job losses, direct physician, hospital, and pharmaceutical bills.
Is this the “free market” we should return to?
Moreover, the “free-market” system that existed for 40 years before the ACA produced the highest cost health-care system in the world, and health-care outcomes (life expectancies, maternal and infant mortalities, recovery rates, etc.) that were little better than those of third-world nations. Every other developed nation in the world spends far less than we do and gets better results.
Is this a “free market” we should be proud of?
And mandates? As a nation we are awash in mandates. If you violate the mandate you are fined or face other sanctions, e.g., if you drive a car, a taxi, a commercial truck, there are various speed limits, or limits on hours of work; exceed the limit, pay a fine. You must also carry liability insurance; if you don’t or won’t you face loss of your license. Run a restaurant or other food service business? You must meet health and safety standards; if you don’t meet the standards or fail inspection, you’re shut down and/or your goods are held off the market.
The more one thinks about mandates, the more one sees how widespread and necessary they are. Air and water pollution-control requirements that industries must meet; the licensing of doctors, dentists, and lawyers to protect the public; building and safety codes to protect occupants; occupational safety requirements to protect workers. These are all requirements that must be met; mandates that if not met give rise to fines and penalties.
In the ACA there are only two mandates, and both are necessary to keep insurance costs down, to optimize the benefits of health insurance, and thereby reduce overall health-care costs.
The first comports with fundamental insurance principles: the larger the pool of insured, the lower average insurance costs will be, so everyone must have health insurance. Refuse insurance, pay a fine; keep refusing, pay a larger fine. It’s like speeding.
The second ACA mandate simply puts a floor under all health insurance policies. Every policy must cover basic health-care needs: outpatient services, emergency services, hospitalization, maternity and newborn care, mental health and substance-abuse services, prescription drugs, rehabilitation (for injuries, disabilities or chronic conditions), lab services, preventive/wellness programs and chronic disease management, and pediatric services.
Co-payment and annual deductible requirements geared to one’s income are part of this mandate. Nothing in the ACA prevents the more affluent from obtaining whatever level of health insurance coverage they need, want, or can afford. The less affluent are assured that minimum health-care needs will be met on an ongoing basis. Hospital emergency room costs will shrink. The overall health of the nation’s citizens will improve.
In sum, the benefits of the “free market” and the fear of “mandates” are both vastly overstated. Republicans need to get over it. The reality is more, not fewer, people in our nation need access to minimum health-care insurance at costs they can afford.
Anything less demeans us as a nation.
Orlando Delogu of Portland is emeritus professor of law at the University of Maine School of Law and a longtime public policy consultant to federal, state, and local government agencies and officials. He can be reached at email@example.com.