On Tuesday, Ryan tweeted an argument that he and other conservative leaders have made many times before: “Freedom is the ability to buy what you want to fit what you need. Obamacare is Washington telling you what to buy regardless of your needs.”
There’s some truth in that second sentence. The Affordable Care Act forces insurers to sell to people with pre-existing conditions. Plans must cover “essential” services including mental health treatments, maternity care and rehabilitation. Additional provisions cap consumers’ out-of-pocket spending and prohibit insurers from selling plans with annual or lifetime limits on payments.
And, of course, there is the individual mandate. People who decline to obtain coverage must pay a financial penalty, unless they can show that the premiums would be unaffordable.
But do these requirements really mean less freedom overall, as Ryan argues? For many Americans, these requirements and the law as a whole have led to more freedom, sometimes in dramatic ways.
One key reason for government regulation of insurance is that the product is inherently complex, making it hard for most consumers to understand in advance what a given policy will actually cover. In the old days, people could find themselves owing huge bills for hospitalization, rehab or prescriptions because they only discovered after they got sick that their junk or “mini-med” plans left out whole swaths of services or covered just a few thousand dollars worth of charges.
These folks were also easy marks for scams, as state insurance regulators fought a losing battle to keep shady carriers from preying on people without access to decent coverage.
In this respect, the current rules on insurance are no different than any other set of consumer protections, like food safety rules for restaurants or car safety requirements for manufacturers. For buyers, such regulations mean the freedom to eat without getting sick or the freedom to drive without getting killed.
But there’s a much deeper sense in which insurance regulation specifically, and the Affordable Care Act more generally, leads to more freedom rather than less.
Prior to 2014, when the law took full effect, many people with pre-existing conditions could not buy useful coverage on their own because insurers would not sell it to them or because the available policies didn’t cover the services they needed. Even insurers that wanted to offer comprehensive policies had to be wary, because promising solid coverage of a disease like diabetes or HIV was sure to attract people with that condition, driving the insurer’s costs way up.
At the same time, millions of people could not obtain insurance for a very different reason. They simply didn’t have enough money to pay for it. Any insurance-related freedom these people had was purely imaginary, like the freedom of the poor to buy a yacht or a mansion, or the freedom of those without savings to retire at age 50.
Yes, the Obamacare subsidies to help these people get insurance require some very wealthy people to pay higher taxes, just as the rules on plan benefits limit the types of products that insurers can sell. But the taxes and rules mean that fewer people end up worrying about crippling medical expenses, while more people get treatment for painful, debilitating or even deadly ailments.
The health care law has also provided another type of freedom: More people have a real option to leave a job with a large employer, which previously was the only reliable source of private insurance, in order to start a new business ― or, perhaps, to work part-time or to stay at home to care for a child or sick relative.
“It is really incredible that this shift from involuntary part-time to voluntary part-time is not more widely known,” Dean Baker, co-director of the Center for Economic Policy and Research, has written. “It is a very important outcome from the ACA.”
To critics of the Affordable Care Act, these gains are not worth the trade-offs they entail. Ryan in particular keeps asking, as he implicitly did in Tuesday’s tweet, why people in good health should have to pay extra for policies that cover medical services they figure they won’t need anytime soon. This is a perfectly legitimate argument, one that’s popular in the part of the conservative universe that Ryan and most other Republicans inhabit these days.
But a major goal of insurance is to protect against the unknown ― the possibility of developing cancer, having a debilitating car crash or contracting a severe infection. A major goal of social insurance programs like Obamacare is also to protect against random accidents of birth or circumstance ― whether it’s a congenital condition like cystic fibrosis that will need a lifetime of care, pollution-induced asthma that will cost thousands for inhalers and medications, or two X-chromosomes that will likely lead to some form of reproductive health services.
“Some [Obamacare critics] have expressed concern that this resulted in a one-size-fits-all benefit package,” said Karen Pollitz, senior fellow at the Henry J. Kaiser Family Foundation. “But it also ensured that key services would be covered in the event of an illness or injury.”
The basic idea here is the same one that undergirds cherished programs like Medicare. Conservatives once attacked Medicare, too. In 1961, Ronald Reagan warned that if it became law, then “you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.”
More than half a century later, Medicare hasn’t created a totalitarian dystopia. Instead, it has allowed generations of seniors to access the medical care they need, while sparing them the hardship and indignity of financial ruin. That’s arguably a huge increase in freedom, much like the Affordable Care Act seeks to deliver now.