Health Policy Reform Redux

The United States has struggled episodically since at least the Truman administration to create a national health care system that would ensure access to insurance and to services in a fashion not dependent on employment status (and employer willingness). Meanwhile, in the sixty or so years of this long running public conversation, health care costs have continued to rise faster than the rate of inflation and more and more employers are either decreasing their support of health care benefits for their employees or ending such benefits altogether. The result of these trends is a system in crisis in which increasing numbers of Americans do not have access to affordable health care. The consequence, as the long-term trend of rising costs and decreased employer willingness to provide health care insurance continues, is more than 30 million citizens without routine access to health care. This ongoing concern prompted Barack Obama to make the issue a central one in his campaign for the presidency in 2008 and finally resulted in passage of the historic health reform act in 2010, which sought to create state- level insurance exchanges and to expand the existing Medicaid program for the poor, to provide the access to health care that employers increasingly were unwilling to offer.

The central reason for the decades-long debate concerning health system reform and the principal cause of that controversy now is widespread concern (but especially among conservatives) that any alternative to the employment-based system in place would represent the “socialization” of a major share of the United States economy. Those advocating change have thus routinely been portrayed as socialists and enemies of the American way of life. Indeed, House Speaker John Boehner made exactly that argument in his recent public comments alleging the 2010 reform law represented a horrific turn in American public policy that the U.S. Supreme Court must overturn. The GOP has assumed a stance of implacable opposition to the 2010 law, including leading the charge to ask the nation’s high court to overturn it. Ironically, President Obama adopted the law’s central provision requiring Americans to obtain insurance, rather than moving toward a single-payer government-run system, implemented by all other western democracies decades ago, following a proposal first advanced by the conservative Heritage Foundation. He did so, so as to avoid the very charges now nonetheless being leveled at the reform. But that fact has not mattered, as the Republican Party has fought all the way to the Supreme Court this last week.

Indeed, oral arguments before the Supreme Court concerning the nation’s new health care law clarified several of the arguments at play and also made plain that critics are not proposing to address the major trends that created the impetus for change. Instead, they appear to aim to reduce still further access to care for the poor and the un- or under- insured. Justice Anthony Kennedy noted in oral argument that there is an alternative to the current law’s framework, which requires individuals to purchase health insurance: a single payer (government –run) health system. While the justice did not say so, he also might have pointed out that President Obama avoided such an approach believing, rightly as it happened, it would result in traditional opposition. Boehner and others in the Republican Party also criticize the reform for requiring individuals to obtain insurance and for “curtailing” states’ rights. Let me speak to each of these claims briefly because each is interesting unto itself.

First, regarding opponent’s arguments about “socializing” a large portion of the economy, it is not clear what precisely is being suggested when this claim is made. Private providers (as now) will still largely deliver health care under the new law and private insurers will offer the insurance being discussed. So, in the sense the Speaker alleged, the claim on offer is simply not the case. The government is not “taking over” a huge chunk of the American economy, nor displacing the traditional roles of private health care providers and insurers. Government is, of course, regulating the health care insurance market, but it seems clear that such is required, whatever the framework, for long-settled reasons and the GOP has never previously questioned that imperative.

Second, while the law requires individuals to purchase health care insurance in some form, including via the new exchanges, most analysts, including the Heritage Foundation’s staffers who designed the provision originally, have contended that the national government’s right to do so was constitutionally long-settled under court interpretations of the Commerce clause (Article 1, Section 8). Nonetheless, this approach has emerged as a central point of attack for the GOP, which argues it is an undue abrogation of individuals’ rights to choose as they might wish. The opposition seems to be borne more of ideological fervor and partisanship than jurisprudence, but the willingness of many on the current court to adopt ideological positions and press them into law has thrown the matter into a state of continuing uncertainty.

Third, critics contend that the health reform law curtails states’ rights by demanding that states participate in an expanded Medicaid program. This claim appears strange for two reasons. First, no state is required to participate in the program and second, states pay a much smaller percentage of the costs of the proposed program expansion than does the national government. Moreover, the nation has not required that states change their current very unequal levels of Medicaid reimbursement and support for the program in the name of ensuring national uniformity. Thus, rhetorical allegations to the contrary, this is not a case of forcing “one size fits all” or demanding similar behavior from each state. Instead, it continues America’s long tradition of nationalizing, without centralizing, public services of various sorts.

Finally, the GOP has not directly offered an alternative to address the continuing and worsening issues of health care access and affordability for millions of Americans. There is no Republican alternative to the health reform act except to call for repeal or a judicial determination of unconstitutionality. Either outcome would discontinue benefits already available under the law and prevent the realization of others expected. Nonetheless, indirectly, the GOP has suggested an alternate course in its recent House approved national budget proposal. That document calls for deep cuts in Medicaid and related social services funding and additional tax cuts for the most wealthy in society. As such, it implicitly suggests a health care course for the poor and for those whose jobs no longer offer access to health insurance. In this plan, those individuals would increasingly fend for themselves, and to gain access to care would require continuing recourse to emergency room services. That policy course would impose very large costs on those who have medical insurance, since institutions spread the cost to those who are covered by policies, thus increasing premiums and direct costs, and also impose costs on the affected institutions, the public treasury and the poor. Notably, it would do so without high visibility to the broader population.

In sum, given current conditions of full-throated ideological brinkmanship, ongoing efforts to undo the Patient Protection and Affordable Care Act of 2010 and continuing political efforts to reduce government services for the needy on partisan grounds, the nation’s long-term inability to address its health care needs in public policy looks set only to continue. That result is lamentable not only for the families who may lose promised services, but also for the long-term opportunity costs it represents, assuming current trends in rising health care costs and decreasing access continue.