Is the ACA Un-American?

Saturday, May 4, 2019

Several courses during my MPH year have begun with familiar statistics; according to data from the Commonwealth Fund’s report, the U.S. is the top health care spender per capita among wealthy countries, yet it ranks at or near the bottom for most health outcomes.

High costs per unit as well as a long history of perverse incentives in the health care industry have played a role in earning us this less than enviable reputation.

The most recent major health care reform, the Patient Protection and Affordable Care Act, seeks to remedy many issues that plague the American health care system, including poor access and misaligned incentives, while promoting value-based care.

Although the ACA has expanded health coverage to 20 millionpreviously uninsured people, the current administration continues to threaten to put an end to itand has promised to deliver an effective ACA replacement.

Several individual key components of the ACA have also been fiercely attacked by Republicans since its passage in 2010; some of them have been changed and gone unnoticed by the general population and threaten to disrupt its stability.

But it is a faulty solution to cherry-pick aspects of the ACA that underscore fairness (e.g. exclusion of pre-existing conditions) while leaving out the mechanics that ensure its sustainability.

The 2012 Supreme Court ruling attenuated one of the ACA’s main pillars (i.e., Mandated Medicaid Expansion), while upholding the individual mandate, which dictates a legal obligation to obtain insurance or face a federal penalty.

In December 2017, however, Congress approved the Tax Cuts and Jobs Act of 2017, which reduced the federal penalty to $0.

Many consider this reduction an effective repeal, since, starting in 2019, individuals without insurance are subject to a federal penalty of $0.

The reduction to the federal penalty is worrisome because 1) younger and healthier low-cost individuals, who subsidize the sicker and older populations, are the most likely to disenroll, resulting in adverse selection (whereby the health insurance risk pool is dominated by “high-cost” “sicker” patients) and 2) the negative impacts of removal of the penalty may be increasingly felt over time as awareness increases within the general public; at present, an estimated two-thirds of the populationis unaware of this change.

Some estimate that overall enrollment will decrease by at least 4%.

Health insurance enacts a redistribution of wealth and risk.

Broad participation lies at the crux of a sustainable health care system, with healthy individuals contributing to a pool of funds that subsidizes the sick.

Why does the U.S. struggle to understand this?

One can surmise that the principle of universal health care is at odds with quintessential American ideals of freedom of choice and individualism, which rebuke any notions of government interference in individuals’ choices and actions for which they alone are responsible.

Is it reasonable that those in “perfectly good” health be expected to contribute to health insurance?

Someone who does not plan to have children may argue that they should not pay for obstetrics coverage.

Those who strive to maintain healthy lifestyles may deem it unfair to be included in the same insurance group as overweight hypertensive individuals.

Except, health is the result of complex interactions between behavior, genetics and the environment, which is in turn tied with ever-growing inequities in the U.S.

We may only recognize the value of comprehensive insurance and our financial fragility when personally confronted with exorbitant health costs.

The argument that one should be able to pay for healthcare when and if one needs it is a fallacy that has led to unsuccessful insurance markets like New York’s “adverse selection death spiral” in the 1990s.

In most other wealthy countries with less per capita spending and better outcomes, the principle of solidarity applies to health insurance coverage.

In other words, there is no rumination on who is deserving of care and the health system is able to spread risk across a balanced and large pool of beneficiaries.

Even if the principle of solidarity is not indelibly integrated into the American psyche, American society is becoming increasingly cognizant of the inequities that plague the U.S.

Along with the public’s habituation to essential ACA provisions, these forces are compelling patients and patient advocates to mount pressure to save the ACA.

Spreading risk across a larger pool of beneficiaries by means of policies that promote universal coverage is key to attaining an equitable and sustainable health insurance.