The Republican conundrum posed by King v. Burwell, which is awaiting a decision from the Supreme Cort, would eliminate subsidies for federal exchanges in states that did create state exchanges. This is at some level both amusing and befuddling. Many on the Republican side of the aisle are, of course, concerned that a decision favorable to the Republican view of the Affordable Care Act (ACA) will create a political disaster for Republicans, at least at the state level (governors and state legislatures). If 7.7 million people lose their healthcare because they can’t afford it due to the lack of a subsidy, then the ire of those individuals, and potentially of the healthcare provider community, could turn rapidly against Republicans. This would be the classic “win the battle, lose the war” scenario.
Let’s take a quick look at different levels of potential healthcare consumers. The expansion of Medicaid was intended to provide a vehicle for securing healthcare for those who could not afford it, even with a subsidy, the implementation of which has been refused by many Republican-controlled states. What is the result? Those people go to the emergency room. Who pays for that care? Then, there are those who are eligible for the subsidies that make healthcare premiums affordable, and for whom the loss of the subsidies will result in unaffordable healthcare. What is the result? They go to the emergency room. Who pays for that care? Then, there are those who are not wealthy, but are not eligible for subsidies — we used to call them middle class — and the wealthy, for whom a decision striking the subsidies has no direct immediate impact.
{mosads}There are a number of proposals coming forward from folks like Sen. Ron Johnson (R-Wis.), a well-known Tea Party favorite, that all revolve around the idea that there should be an extension of the subsidies until the law can be fundamentally changed, which presupposes a Republican president in 2017, as well as accepting the myth that the market would create more reasonably priced policies. History prior to the ACA’s passage does not demonstrate a market that was driving down premiums. Of course, you can accomplish premium reduction if you strip the policies to the point that they have no effective value to the insured or to providers.
Fundamentally, if the idea is to do away with the mandate compelling individuals to buy insurance, then the logical extension is that if an individual is unable to provide proof of capacity to pay at the time of treatment, then the healthcare provider should not be required to provide it. If the goal is to have a truly functioning free market and freedom of choice, then you cannot compel activity on one side of the equation and not the other. Of course, the likely result would be that people would die for lack of treatment, which I suspect and hope is not an outcome desired by those who are opposed to the Affordable Care Act.
There are many things wrong with the Affordable Care Act, but the basic principles are reasonable and appropriate, in my view. The most fundamental principles, as a member of Congress who voted for the legislation, are spreading the risk and providing access to care through insurance coverage. This is the way civilized societies act. It may be that for some individuals, there should be the freedom to have a high deductible plan or no plan, but allowing those individuals to assert a right to care impinges upon my freedom. If they seek care, then they must prove the ability to pay, otherwise the healthcare provider should be free to refuse care.
Nowhere in the anti-healthcare lexicon is the word “responsibility” uttered; only freedom is proposed. A logical analysis, and one that the vast majority is afraid to ponder, is if you refuse to purchase insurance, why can’t you be compelled to prove you can pay? That’s how a market really works.
I am all in favor of giving people free choice, but then they must accept full responsibility.
The ultimate answer to “Who pays for healthcare?” is, in reality, those of us who do have health insurance, and those of us who pay taxes, because the providers will have to recover those costs from someone.
Owens represented New York’s North Country from 2009 until retiring from the House in 2015. He is now a senior strategic adviser in the Washington office of McKenna, Long and Aldridge and a partner in the Plattsburgh, N.Y. firm of Stafford, Owens, Piller, Murnane, Kelleher & Trombley, PLLC.