Listening to years of bickering over the ACA--and bickering is indeed the word to use here--has left me with a sense that we need to restart this 'conversation' from first principles. And after thinking about health insurance from first principles, I've come to the realization that the biggest problem with health insurance isn't whether it's controlled by the government or private insurers (although there are indeed problems associated with both of these). The biggest problem with health insurance is the very idea of health insurance itself. 'Health' and 'insurance,' as we understand them, are wholly incompatible.
Consider, for example, the bickering over the 'individual mandate' imposed by the ACA. Conservative opponents of the ACA and the mandate argue that it's immoral to force healthy, young people to buy health insurance. Supporters of the individual mandate (notably, a conservative idea) argue that it's necessary to accomplish the broader aim of the ACA: to bring down healthcare costs and keep premiums low by having a broad, 'diverse' pool of insurance customers.
At what point does someone realize that this is a completely stupid argument?
By looking at healthcare from an insurance perspective--which is to say by minute calculations of risk akin to those done by car insurers, hedge fund managers, and casino operators--it would certainly seem silly to force a healthy 25-year-old to buy health insurance. At the same time, it would certainly seem necessary to have that healthy 25-year-old as part of the client pool to contribute favorably to an insurance company's risk profile, to offset all those expensive old people who run higher risk of needing care, and needing it paid for. But this is an ass-backwards way of looking at the situation for one very simple reason: it's both socially and morally irresponsible to take risks with one's life.
To explain this further, consider that healthy 25-year-old. Most people that age don't get sick, don't require hospital care, don't require long-term care...except when some of them do. Young people can get catastrophically sick; hit by cars; break bones; overdose; get pregnant, etc. And when these things happen, as they inevitably do, however atypical they are from a risk assessment standpoint, no reasonable person in our society would say that we should deny these people care if they're not 'insured.' A physician is under ethical obligation to provide care. A hospital can't turn away a gun shot patient with no health insurance. And no one but the most extreme Randian sociopaths would argue that it should. As a society we've already made it clear, on a number of fronts, that even if our policies don't reflect our values, our values favor the preservation of human life. The left concerns itself with the risk to life born by the uninsured; the right concerns itself with the prospect of 'death panels' that decide precisely when care will no longer be administered to the dying. And the private medical sector makes these choices every day. And never without regard for doing the most we can with what we have to preserve life.
And herein lies the fundamental problem: unlike when you wreck your car without auto insurance, you can't just junk a catastrophically sick person, whether they're insured or not. Healthcare reformers have argued for ages now that because of this dynamic, we have to be mindful of the costs to government and taxpayers of 'free riders' who are without insurance but nevertheless must go to hospital to get care when they need it. The risk associated with ill health, then, is not a risk at all. It's always a guarantee of care, at least from a moral standpoint. You insure cars; you can't insure people. It's a moral impossibility.
So if we know that we'll always provide care to the 25-year-old who didn't purchase insurance, why are we treating this situation as a matter of risk management, or as a matter of insurance?
The alternative is to be honest with ourselves about our values, rather than abstracting them (and thus contorting them) by running them through competing risk analysis protocols under the guise of 'efficient' provision of 'insurance.' Access to healthcare, therefore, must be understood as a right, not a risk. In ideological terms plenty of people will lose their respective heads arguing against the idea that healthcare is a right; and yet if you ask any of these people whether they think, therefore, that someone who hadn't the foresight (or the money) to insure themselves should be left to suffer and/or die, none of them will actually say we should just let people die. That would be mortifying, indeed, sociopathic. In practical terms, therefore, we're actually fairly united in understanding access to health care as a pretty basic right. It's time we start treating it that way in policy terms.
