Health Scare for Everybody

Health care is a complex and sensitive topic and a lightening rod for controversy because it affects anyone who breathes. There is so much passion in this debate, because we all know someone who is sick, or who has been chewed up and spit out by an increasingly out-of-reach healthcare system. We have friends who are deep in debt because they had the misfortune of getting the wrong illness at the wrong time. Ours increasingly feels like a society in which being ill is a crime, punishable by debt.

I think we can all agree that our current health insurance model - otherwise known as the 'status quo' is unsustainable and broken. Take a look our increasingly plutocratic society, and our increasingly convoluted and restrictive health plans. Among all industrialized nations, the United States is the only one without some form of universal health care. We have 50.7 million (and rising) uninsured Americans, higher premiums (10 percent increase in 2011), and pre-existing condition clauses that unfairly target the sick and poor. The problem is so vast and systemic that it will take more than a few band-aids and tax incentives to fix it. 

The Affordable Care Act (ACA), or 'Obamacare,' as some call it, is poised to become one of the most significant and sweeping pieces of domestic legislation to hit the United States in well over fifty years.

ACA is a relatively ambitious law. It's intended purpose is to strike at the heart of our health care crisis by insuring millions of uninsured Americans: those who cannot afford coverage, those who have been denied coverage, and those who are one pink slip away from losing coverage.

It extends coverage for 3 million Americans 26 and under on their parents' plans.

Abolishes annual and lifetime limits for individual care.

Forces Insurance companies to spend at least 80 cents on the dollar for actual care, as opposed to administrative and overhead costs.

Closes the so-called 'doughnut hole,' which found seniors paying their full premiums and still not getting their prescription drug costs covered.

Incorporates tax credits and incentives for small businesses and individuals who comply. Establishes exchanges and pools, along with subsidies for those who cannot afford to buy into plans as-is.

Ends denial of coverage due to pre-existing conditions (pre-existing restrictions for children have, in fact, already been lifted under the ACA).  

Expands Medicaid for States who choose to participate. (Interesting to note that despite the expansion being 100% covered by Federal money for three years, and still significantly subsidized thereafter, several Republican Governors have already pledged not to participate as a kind of protest, leaving their seniors in a pretty awful position).

ACA is arguably a step in the right direction, a way for us to begin caring for all citizens, not just the few who can afford it or have been lucky enough to avoid catastrophic illness or economic misfortune. In this sense, the ACA, with it's specific fixes for notorious problems, is fundamentally preoccupied with the viability of those specific processes rather than the broader philosophical implications of how any those results are being achieved. It's far from a Socialist program. It's a merging of Federal and private interests - a marriage, if you will, between representative Government and the free market.

Unfortunately, the very participation of Government still raises big red flags for limited Government advocates. Republican alternatives to ACA can be summed up with one phrase: 'repeal and replace.' They would rather see the entire law pulled out by the root than watch a single provision take effect, all because of what the law represents for them philosophically. Their sole purpose is to get Government out of the healthcare business altogether. The 'replace' part of 'repeal and replace,' as vital as it should be, is more of an afterthought. The Republican health care playbook amounts to an anti-tax, pro States' rights argument wrapped up in half measures and re-tooled, wonky economic ideas. The Republican agenda, in short, is preoccupied more with it's philosophical overtones than the viability of its specific processes, and the most vital goal is the destruction of 'Obamacare,' and the subsequent destruction of his legacy (which has been the prime target since January 2009).  

The ideal Republican healthcare landscape offers a varied assembly of private health insurance plans that can be purchased by citizens no matter where they live. It treats health care as a product like any other, rather than something like a societal human right. It treats health care in a strict economic sense - as just another commodity, like broccoli, or oil shares, or energy, to be available across State lines and integrated into a free market, where it then ostensibly thrives. Republicans, by stripping health care of its moral and societal dimensions, hope to make this an issue of sole economics, one that addresses Americans' fears about an ailing economy. Given that their nominee is running on a platform of economic virility (and little else), this approach makes sense for them.

ACA opponents would rather keep health care options at the State level, and health care decisions at the individual level. Republican lawmakers are not opposed to changes in the way health care is provided, so long as it rejects anything resembling a tax and adapts to the demands of a dynamic marketplace, rather than the requirements of a Federal mandate. They have pledged to pore over the existing legislation and fight taxes therein (such as the medical device tax). Insurance companies are also eager to set caps on how much they can pay out. Some of them are doing nothing but campaigning for Romney - if that happens, they can begin dismantling the law altogether. Now that the single payer mandate has been deemed Constitutional by the Supreme Court, Republicans must work with the bill however they can. However, the recent Constitutional validation is not so much a victory as you might be led to believe. 

The recent SCOTUS majority deemed the ACA's individual mandate provision (the "backbone" of the law) Constitutional. Liberals cheered, but it was a Pyrrhic victory. The ruling alternately allowed the law to stand whilst simultaneously limiting Congress's future authority in regards to interpreting enforcement of State activities as defined by the definition of interstate commerce in the Commerce Clause. Even if you are a Constitutional Scholar (and very few of us are), your view of the issue is going to be framed by your opinion on how the Constitution should be interpreted here. The truth is, those interpretations have not remained static throughout our country's history, and probably never will.

The Commerce Clause (Article 1, Section 8, Clause 3) of the U.S. Constitution grants Congress the authority to "lay and collect Taxes, Duties, Imposts and Excises, to . . . provide for the General Welfare of the United States." While Justice Roberts based his ruling on the invocation of Congress's right to levy taxes, he simultaneously struck down Congress's right to invoke the Commerce clause when defining interstate commerce. This definition has historically been interpreted very broadly, and has resulted in seminal legislation, including that affecting workers' rights, New Deal programs and Federal civil rights laws. It is, in essence, a keystone provision from which much sweeping historical Federal reform has derived, and the ruling essentially plucked that keystone from the wall, leaving Congress with little future authority in such matters.

The irony of the Supreme Court's decision is this: had a single payer health plan passed in the Congress, it would have likely been upheld in the Supreme Court. Justices signaled as much during oral arguments earlier this year. The involvement of the private market - in other words, the fact that ACA is a compromise between single payer and fully privatized health care - has resulted in all these problematic legal issues. ACA, while currently upheld (save the Medicare provision), hangs by a legal thread, and with all the political pressure bearing down on it, and in an election year. It's future is far from ensured.

Nobody is against reform - it's the structural design of the reform that people disagree on. All parties agree that something has to change. Opponents of the new law believe it will  fundamentally and irreparably alter the relationship between Federal and State Governments, and between Government and the individual, thus transforming the fabric of our democracy into something unrecognizable. These ACA opponents fear expansion of Government authority in all personal matters, particularly those related to health and privacy. They fear any law that imposes what amounts to a tax penalty on citizens who choose not to purchase a product. 

They see Obamacare as a symbol for the Obama Presidency, a symbol for Big Government takeover; a symbol for the dissolution of a Republic founded on personal liberty, personal growth, and individual responsibility. They see Obamacare as a full bore attack on free will and the right to make one's own decisions in regards to healthcare, or any other commodity. They are terrified and angry. Glenn Beck recently bragged that the Tea Party will win because Liberals don't understand them. It is possible that he is right. The fear and terror of encroaching dystopia may be steeped in panic and hyperbole, but never underestimate the galvanizing properties of fear.  

So, let's say they get their wish and Obama loses in November. Let's say the House votes to repeal ACA, and then ultimately, it does get struck down. What next? The champions of personal responsibility win the right for the individual's 'freedom to choose.' What sort of a win would that really be with real, true reform?

After all, winning 'freedom to choose' in our current healthcare system, or even one slightly improved from what we have now, is a dubious honor. In our current system, there are few affordable choices, even less so for individuals who find themselves facing a life threatening illness or saddled with immense debt from one or two hospital stays. 

There are other issues I could touch on if I were more inclined to go into specifics. For instance, the insurance death spiral phenomenon and how it necessitates mandates and something called guaranteed issue. Democrat and Republican plans both allow for pools and exchanges of higher risk and lower income patients. There are inevitable (and problematic) comparisons between mandatory health care insurance and mandatory auto insurance being made. In fact, there are so many components to this that it's easy to get lost in the web, and lose sight of what really matters. How do we get health care to people who have been let down by a broken system? What is the best way to do it without taking away their fundamental freedoms?

The debate being waged, underneath all the the numbers and projections and economics, is this: do we share in our responsibilities, essentially 'paying in' to a system constructed to provide basic health care for all, or do we give ourselves economic incentives in the marketplace, keeping health care decisions individual and private? This is a moral, philosophical debate about duty and society. Were it proven that the ACA were the best, cheapest, easiest way to get health care to all, the debate would still rage on because of the ideological stakes. Were it proven that ACA was the absolute wrong course, valid concerns about availability and affordability of health care in this country would still rage on. 

The best way for me to frame this debate is to consider what it means to be free. Let's take two citizens - "A" and "B" and compare their freedoms.

Imagine you're U.S. citizen "A," in a world where ACA has taken effect. You feel compelled to participate in a single program under threat of penalty. You feel threatened by what the ACA represents, either because you don't want or need health insurance, or your simply oppose the mandate on ideological grounds. You feel your freedom is at stake, and you will fight tooth and nail to strike down the law that requires you to do anything you don't want to do. All you want is to be more free - free from taxation, free from punitive obligation. You must feel awfully imprisoned by laws that you oppose. It must be infuriating to feel less free than you know you should be.

Now, imagine you're a U.S. citizen "B," living in a world where the myriad reforms of ACA never happened. You facing a restrictive, wasteful and inaccessible healthcare system. You still grapple with mounting debt from illnesses long since treated, but new symptoms have begun to surface and you don't know how you're going to afford the treatment. You are beset by conditions deemed 'pre-existing' by the insurance companies and your premiums skyrocket, while your eligible coverage narrows and narrows. Your monthly prescription cost just went up again. If you get sick, it's sometimes better for you just to stay home because you can't afford the financial burden of participating in a system where your premiums don't cover a whole lot. What a horrible position to be in. If you're in this scenario, you are in the majority. In fact, if you are in this position, you live in the America that precipitated the passing of ACA. You are - for lack of a better term - most of America. You feel awfully imprisoned by a system that seems devised to thwart you. It must be infuriating to feel less free than you know you should be.

If we look at Citizens "A" and "B" and try to assess a meaningful comparison of their respective freedoms, or lack thereof, we may find ourselves lost in a maze of moral relativity and confusion. This is no accident.

There are different kinds of imprisonment, be they the restrictions of a broken system or the mandates of a new law. Who is anybody to judge which imprisonment is worse, and which deserves to be overlooked for some greater cause? That is the defining, overarching question that - at least so far as I can tell - has not found, or even sought, a meaningful answer.


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