Policy Wonk: The Republican health-care mantra is absurd

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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 orlandodelogu@maine.rr.com.

  • Little crow

    I would ask Mr. Delogu why it is illegal for me to buy a health insurance policy that I want from an insurer that wants to provide it? Why should a bureaucrat or politician prevent me from getting the coverage that I think is best for my situation? Please state an example of a system that has provided more goods and services to more people (especially poor people) than free markets.

    • EdBeem

      “Nothing in the ACA prevents the more affluent from obtaining whatever level of health insurance coverage they need, want, or can afford.”

      • Chew H Bird

        However, I cannot purchase plans that are not authorized in Maine… I remember a remote employee that I had years back who lived in Florida and our insurance plan had no option for him to have authorized medical care except for “out of network options” and so they refused to cover him… Regardless of the ACA, there needs to be a significant intelligence upgrade regarding regulations that make no sense in the modern world.

        • EdBeem

          If you can pay for it, you can get it on the individual private market, which is what Republicans advocate.

          • areyoukiddingme

            I’m late to this column. But EBeem you are simply not correct and as always I write to make you a better informed person. The content of individual coverage is dictated by the ACA. If it doesn’t meet the minimum’s of the ACA it simply doesn’t qualify you as having coverage under the ACA. A really big issue.

          • EdBeem

            . Perhaps I wasn’t clear enough. I was referring to health cover age purchased on the private market Not under the ACA.

      • Little crow

        The ACA is loaded with mandates that require people to buy all sorts of coverage they don’t need, and it prohibits them from buying insurance from another state. Sen. Ted Cruz has an amendment pending that would allow insurers to sell any policy they want, as long as they offer at least one policy that complies with ACA requirements, but the amandment isn’t going anywhere. Apparently Republicans don’t trust Americans to take care of their own needs any better than Democrats.

        Perhaps the most insidious mandate of all is the one that forces people to buy insurance or be fined. As Supreme Court Justice Anthony Kennedy dissented, this changes the relationship between the citizen and his government, as it requires the citizen to enter into a private contract; and if the government do that, it can force the citizens to do whatever it wants. For those Progressives who think that’s the way things should be anyhow, congratulations! Since passage of the ACA, you are now a lowly serf and the government is your master.

        • EdBeem

          I am talking about the private market. If you can pay for health insurance without participating in ACA you can buy anything you can afford. If you need public assistance, you have to play by the rules. The real problem with the ACA is that the fines were not enough of a deterrent. You need everyone in the coverage pool. That’s where single-payer universal coverage comes in, Medicare for All. It’s like Social Security. You can have all kinds of retirement plans, but you still have to pay Social Security for the system to work.

          • Little crow

            I am also talking about the private market, which is the only kind of insurance I have been able to buy because I am self-employed. Those mandates I mentioned aren’t like retirement plans; they are restrictions on what can be offered, and they apply to all insurance policies. The policies that are available in the private market are designed by politicians, not you, not your insurance company.

            Last year I had a private policy:$7,500 deductible that cost $640 a month, then the company cancelled everybody in the state of Maine, so I went on Obamacare. That cost $1,180 a month for a $5,000 deductible – almost double the premium. The policy I had was bad, but Obamacare was worse. I don’t want the government doing anything for me that touches my private life. I am an expert at taking care of myself, and I want that option.

  • Chew H Bird

    The last 40 years is the problem with this opinion… This is the time frame where housing prices spiked astronomically, gasoline prices spiked and we had waiting lines for fuel, interest rates skyrocketed, and we went into a financial crisis… The we add the huge spending increases for our military and the expansion of social welfare programs, and government regulations began creating major overhead costs for USA businesses. Next comes the technology boom and the migration of formerly US jobs to overseas workers and US manufacturing takes a dive. We should not forget the environmental concerns that have raised the cost of many products and astronomical increases in the cost of education to where we now have “non-profit” institutions with billion dollar endowments. Add to this the multiple “too big to fail” bailouts of large business and now the instant viral media that promotes their own agenda at the expense of actual “news”.

    So, from the end of WW2 up until the late 1970s we had a fairly stable economy, health care prices have always been expensive but they were affordable for most people, and a single income could often afford to own a home, raise a family, and fund the majority of a college education.

    The last 40 years is where we have made catastrophic mistakes in the role of government. We have made major mistakes in regulatory requirements and mandates. We have made major mistakes in managing public resources.

    I am not saying that all regulation is bad. I am not saying a clean environment is bad. I am not saying that many of our goals are bad.

    I am saying our chosen methods of accomplishing our goals have been riddled with mistakes and our elected leaders and special interest groups, no matter how well intended, are responsible for creating our current situation.

    If the ACA had contained appropriate cost control regulations and requirements, and contained torte reform requirements, we could have insured all of America for less money and less burden. Today, Republican and Democrat posturing is destroying what little remains of the American dream and the creation and implementation of the ACA without the required controls is accelerating the decline in healthcare for all Americans.