At a recent meeting in Washington State an attender denounced the evils of The Affordable Care Act (ACA), or as it has become known “Obamacare.” He argued that requiring compulsory health insurance was a major restriction of personal liberty. When I asked what should happen to someone who becomes ill but does not have any money he replied that “There should be a safety net for such people.” As someone involved closely with state insurance systems this reply shows wishful, almost magical, thinking.
The present “safety net” is so torn that even a short-sighted clown should tremble to use this trapeze. If you are poor and uninsured you rely on the charity of individual providers or hospitals. The hospitals are required to provide some charitable care, but do remember to schedule your illness in January before the allowance is used up. Few doctors wish to or can provide unpaid care. An uninsured person with a major medical condition has “lost the farm” or worse. Most uninsured people either do not have jobs or have jobs that do not offer health insurance. Few are risk takers or freeloaders. The mathematics of small numbers mean that insuring small business groups has high inefficiency.
Why then is there such public antagonism to compulsory insurance? Apart from the concern that this is a tax (albeit possibly efficient), people can always be rabble-roused about the invasive role of government. In 1949 this concern was used by the American Medical Association (AMA) who overprinted Sir Luke Filde’s picture “The Doctor” (Tate Britain) with “Keep politics out of this picture.” But neither the insurers or the AMA are so certain now. Their curious ambivalence is noted by examining their “Harry and Louise” adverts which opposed the reforms proposed during the Clinton administration. Yet now similar videos have been used to support the ACA initiatives, as both health insurers and providers become aware of the economic and political situation. Government subsidized patients are better than none. To paraphrase Hillaire Belloc “keep a-hold of Nurse, for fear of finding something worse.”
Criticism of the ACA is particularly strange because the public is enthusiastic about the national health insurance program for the elderly-Medicare, which – surprise – depends on contribution to a compulsory levy. Remind you of something? No serious politician suggests that Medicare is unconstitutional or should be abolished. In fact some critics of the ACA attack it for potentially weakening Medicare.
The ACA has found itself dependent on some relatively arcane issues associated with federal rights to regulate inter-state commerce. Its future in a politically divided government is uncertain. Medicare was introduced and is revered as part of the great society initiatives. Both ACA and Medicare raise money from individuals to produce an individual benefit. So what is the difference? Could the constituencies vary? As they say “Go Figure.”
Andrew Brunskill was the medical director of the State of Washington Uniform Medical Plan for ten years and then completed a PhD in Health Services Research. His MB, BS is from Newcastle and his US boards qualifications are in public health and pediatrics.