Writing on Inauguration Day, I find it difficult to divert my attention from what is starting and all that is ending, or at risk of it. Since it’s generally ill advised to write about one thing while thinking about another, I feel compelled to choose a topic in that domain. The assault on the Affordable Care Act, or “Obamacare,” is the obvious choice.
The one problem for me and you alike in this area is the volume of ink (or number of electrons) already directed at it. Are there novel things left to say?
I believe there are, and surprisingly perhaps, at a very fundamental level. The contingent particulars ― the number of lives affected, the dollars in play ― have certainly had ample attention. It’s the first principle issue that has received the least. Namely: is it at all true that some version of “American values” and our free-market inclinations in any way justify the Republican opposition to the ACA?
The answer is a surprisingly easy and obvious “no,” and there’s a good chance the decisive evidence of that is no further away than your garage. The evidence is your car.
Most of us drive. To do so on public roads requires that we have auto insurance. It’s not optional. If you drive on public roads without auto insurance, you face fines and penalties, and the potential loss of your license. Auto insurance is mandated by every state government.
Where’s the hue and cry? Isn’t this government intrusion un-American? Shouldn’t we be scrambling to dismantle the auto insurance bureaucracy, rather than accepting the unending parade of commercials for Geico, and Liberty Mutual, and eSurance, and the rest?
We all seem to accept that unless use of our cars is limited to the driveway on Sundays, insurance for all makes good sense. Why? Because your use of a car on a public roadway might affect me. If you are both poor and a bad driver, does that mean I should get stuck with the costs of a crash you cause? We all seem inclined to say: no. You should have insurance to cover the costs of any mayhem you might impose on the rest of us- and vice versa, of course.
In other words, in the area of auto insurance we seem inclined to accept the fundamental role of government in creating fairness, a level playing field, and common rules. We also accept that in this context, free market forces may yet prevail. That they do is just what those competing advertisements for this insurance company versus that tell us. Government establishes the floor for us all, free market forces compete to raise the ceiling.
Health insurance is, or at least should be, viewed in exactly the same way. For one thing, until or unless we develop cars that are both driver-less and passenger-less, the movement of cars along public roads will involve the movement of human bodies, too. How bizarre to require insurance only for the less expensive and eminently more replaceable of the two.
Some form of universal health insurance is the norm throughout the developed countries of the world for good reason. Any alternative is a demonstrably bad idea. We pay for that bad idea in the U.S. in every currency that matters: the needless loss of life from years, the needless loss of years from life, and an absurd number of dollars allocated to medial care producing relatively bad outcomes.
That the ACA is imperfect obviates none of this, nor in fact are its limitations accidental. The ACA was encumbered with flaws from the start by those opposed to it for reasons of ideology they forgot to apply to auto insurance. Consider, for instance, the chaos if some states required auto insurance and others did not. What would happen when an uninsured driver from, say, Rhode Island, hit my car on a Connecticut highway? Gaps and inequities would stress the system, and just such stresses were introduced on purpose into the copious particulars of Obamacare.
I am reluctant to say what I think this rush to repeal the ACA, whatever the consequences, is really about. I suspect there’s no real need. In the context of an orchestrated effort to erase the Obama legacy, it’s rather self-evident. But I can say what it certainly isn’t about.
It’s not about saving lives, or money. It’s not about evidence, or sense. It’s certainly not about the lessons of epidemiology. The one potential surprise in the mix is that it’s not about ideology, either, at least not any ideology applied consistently. If mandating insurance for human bodies is in any way un-American, how can mandating insurance for auto bodies be universally accepted without resistance?
This tendency, by the way, to invoke values or principles or ideology to justify a cause, while overlooking monumental internal inconsistencies, is more norm than exception and redounds accordingly to the deficiencies of our public discourse, and our collective shame. The fuss over medical use of marijuana is a good example. Most of those in the opposition presumably have no clue that medical cocaine has been legal all along; it is used to treat epistaxis, or severe nosebleeds. Many legal drugs are incomparably more dangerous and addictive than marijuana. Opposition is a hollow and inconsistent ideology, signifying no real understanding.
So, too, is the rush to repeal the ACA despite the good it has done, and the far greater good it could do if the sabotage imposed on it at the start were systematically expunged. The drive to dismantle anything like universal health care coverage in America is blithely inattentive to the realities of driving in America, and the government mandated requirements that pertain along the highways and byways of every state, from sea to shining sea.
Director, Yale University Prevention Research Center; Griffin Hospital
Immediate Past-President, American College of Lifestyle Medicine
Senior Medical Advisor, Verywell.com
Founder, The True Health Initiative