Whether you believe history really does repeat itself, or that it merely rhymes, there is something awfully familiar about the direction the debate over the Republican effort to overhaul the Affordable Care Act. Lawmakers and members of the Trump administration are, with increasing frequency, citing the virtues of giving people the freedom to choose the kind of health insurance coverage they want to buy, or to go without coverage at all if they choose to do so.
“Loosen up regulations and mandates, so that Americans can choose to purchase insurance that suits their needs and that they can afford,” he wrote.
On Sunday, Health and Human Services Secretary Tom Price, appearing on Fox, argued the benefits of the insurance system as it was prior the Affordable Care Act. “Before, individuals were able to purchase the kind of coverage that was actually responsive to them. Fit their system, fit their lifestyle, fit their situation in life. That’s the way that you get folks to buy coverage.”
But the idea of allowing people the “freedom” to choose the health care coverage they want raises an obvious secondary question: Are we willing to let them suffer the consequences if they make a bad decision?
We’ve had this discussion already. And not that long ago.
Back in 2011, when the nationally recognized politician with the surname “Paul” was Ron, the congressman from Texas and not his son Rand, now the senator from Kentucky, there was a clarifying moment in the discussion of the future of healthcare in the United States. It came during an early Republican presidential debate after the elder Paul, always more libertarian than actually Republican, had been extolling the benefits of personal freedom when it came to health insurance.
He was asked by CNN moderator Wolf Blitzer about the hypothetical case of a 30-year-old man who chooses to go without insurance, but becomes ill and winds up in a coma. How should society respond?
Paul began by answering a different question.
“What he should do is whatever he wants to do and assume responsibility for himself,” Paul responded, adding, “That’s what freedom is all about, taking your own risk. This whole idea that you have to compare and take care of everybody …”
He was cut off by cheers from an audience that was packed with his supporters, but Blitzer tried to refocus the Texas congressman. The question wasn’t about whether the man should have the freedom to go without health insurance. It was about how the rest of the country should respond if he were to make that choice only to then require expensive care in a matter of life or death.
“Congressman, are you saying that society should just let him die?” Blitzer asked.
Paul’s answer, a mishmash of nostalgia for an imaginary past in which churches took up all those burdens, is largely forgotten. What people remember from that moment was the reaction of the Paul supporters in the crowd. Many cheered the idea of letting Blitzer’s hypothetical 30-year-old die. “Yeah!” they shouted when he asked the question.
The moment was valuable not because it revealed that a few Paul backers took their libertarianism to such an extreme that they cheered the idea of letting a sick man perish in the name of freedom, but because of the disgust that the rest of the country felt at their response.
To the majority of Americans, the answer to Blitzer’s question was obvious and immediate: Of course society shouldn’t let people die unnecessarily because they don’t have health insurance.
It’s a belief so fundamental that it was incorporated into law 25 years before Blitzer brought it up. In 1986, Ronald Reagan signed the Emergency Medical Treatment and Labor Act, requiring any hospital that accepts Medicare payments for emergency room visits also provide treatment to all patients with emergency medical conditions, regardless of their ability to pay.
The United States effectively answered the question then: No, we shouldn’t let people without insurance die.
We’ve just spent the intervening three decades trying to figure out how to pay for that decision.
The EMTLA prevented unnecessary deaths, but it also imposed enormous uncompensated costs on hospitals. They responded by increasing the prices they charged patients whose care was covered, resulting in a vicious circle. As premiums went up, more people lost their insurance coverage, resulting in more people requiring uncompensated care, resulting in still higher premiums; rinse, repeat, ad infinitum.
Many people went without insurance at all, and as premiums went up insurance companies began to sell cheap policies with bare-bones benefits. Too many Americans found out the hard way that while they may have had something called insurance, that didn’t translate into actual protection from financial disaster when they needed expensive care. Crucially, they found themselves landing in ER’s when they hit coverage limits, exacerbating the system’s problems. Healthcare-related bankruptcies were epidemic and millions of Americans went without necessary medical care until that ER visit became unavoidable.
That’s how it was in the era HHS Secretary Price referred to as “before” in his appearance on Fox. That’s how it would be in a world in which Sen. Johnson’s call for fewer mandates and looser regulations on what constitutes health insurance coverage was turned into policy.
We’d be turning back the clock to a time when it made sense to ask what the U.S., as a society, ought to do with a sick person who cannot afford necessary care. But it’s a question we’ve already answered.