Health care reform: Policy, ideology, and ethics

by Kakofonous
Two ethical principles defined the health care debate: personal responsibility and collective responsibility. Each stance corresponded well with the ideology of a pundit, politician, or ordinary citizen defending or attacking the proposal. A liberal supporting the plan would typically repeat the phrase "32 million Americans" several times during the course of his or her defense of the bill, hoping to appeal to a moral sensibility that most share: it is good to help the sick. From that point, he or she would conclude that as a nation we have a collective responsibility to do so. Conservatives would retort that it is not the responsibility of government to spend public funds on health insurance, but the personal obligation of each citizen to maintain his or her health, with universal access guaranteed only to the most basic services, such as emergency care. They would often continue on to say that it is also reprehensible to continue on the current unsustainable fiscal path, and this, despite apparent benefits, is a serious moral issue that merits consideration.
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If we take the most skeptical view on the fiscal basis of the health care bill, the picture isn't pretty. Many conservatives, like Rep. Paul Ryan, ranking Republican on the House Budget Committee, believe that the health care bill uses deceptive techniques to disguise its cost. These techniques would effectively count savings, most prominently those to Medicare, twice. The money saved from Medicare would be used to fund other aspects of the bill, so the cut does not reduce net spending or the deficit. He contends that, were the cuts only counted once, the bill would contribute significantly to the deficit.

… [The Patient Protection and Affordable Care Act] double counts Medicare cost savings. It double counts increased taxes for Social Security, increased premiums for this new CLASS Act.
If you take all the double counting out of the bill, which the CBO can't do because that's the way it's put in front of them, this thing has a $460 billion deficit in the first 10 years, a $1.4 trillion deficit in the second 10 years.
… This bill looks like it reduces the deficit because they raise taxes a half a trillion dollars over 10 years and cut Medicare a half a trillion dollars over 10 years to pay for six years of spending.
So 10 years of tax increases and Medicare cuts with six years of spending makes it look as if this thing reduces the deficit. And then if you double count those tax increases, those Medicare cuts … that's the whole smoke and mirrors. — Rep. Paul Ryan (R-Wisconsin) on Fox News Sunday, February 28, 2010

These suspicions are confirmed at least in part by the CBO: in a post on his blog at the CBO, Douglas Elmendorf, its director, stated that "… [describing] the full amount of [Hospital Insurance] trust fund savings as both improving the government’s ability to pay future Medicare benefits and financing new spending outside of Medicare would essentially double-count a large share of those savings and thus overstate the improvement in the government’s fiscal position." Despite its apparent fiscal shortcomings, the bill seems to be effective at reducing premium costs for consumers, since it provides extensive subsidies for purchasing insurance to many. Projections from MIT economist Jonathan Gruber listed below show savings for consumers in income brackets up to 350 percent of the federal poverty line. These projections are based on the unamended Senate bill, but the CBO does not believe that the amendment would significantly change projections of premium cost. Gruber's estimates incorporate subsidies to give a rough picture of the changes in affordability resulting from the legislation.

To recap: on the liberal objectives of universal or near universal coverage, the bill fares so-so to well, though there will still be significant numbers of uninsured people (around 10 percent of the nonelderly population will still lack insurance in 2016, according to the CBO) even when all of the bill's provisions have been implemented. (It should be noted, running the risk of beating a dead horse, that this is accomplished in a way that conservatives like Mitt Romney and Orrin Hatch have supported in the past.) On conservative goals of fiscal responsibility and cost control, the bill fares worse, with a few important exceptions. Though costs are controlled for most through the use of federal tax subsidies, the root problem of rising costs is not addressed through any particular provision. However, as Ezra Klein notes, one of the most important unsung elements of the bill is the creation of quite a toothy agency called the Independent Payment Advisory Board, which makes recommendations for cutting the costs of Medicare. As many conservatives are fond of pointing out, spending on Medicare and other entitlement programs is one of the more worrisome items on the budget. These recommendations, and other measures in the bill that set up pilot programs and other important research initiatives, will undoubtedly make some dent in the cost curve. The fiscal basis for the bill is, as noted above, probably not as strong as CBO estimates that indicate a deficit reduction of $143 billion from 2010 to 2019; however, since I am neither a CBO analyst nor an economist, I will refrain from making any definitive predictions on that front myself.
So, where does this put us in the broader ethical landscape? The current legislation succeeds in increasing the insurance rate to around 90 percent of the nonelderly population in six years or so. According to a study published recently in the American Journal of Public Health, being uninsured is an important risk factor in mortality, contributing up to around 45,000 deaths a year in the US. However, this claim has been disputed on methodological grounds by David Dranove at Code Red. The gut feeling is, of course, that health insurance contributes at least somewhat to our health. Yet a 2002 Health Affairs article cited by Ezra Klein at The American Prospect calls that intuition into question. The paper suggests that the total contribution of deficient medical care (which includes health insurance) to premature mortality in the US is the second-least significant factor: only 10 percent of deaths. Genetics and behavior are the two most significant, contributing around 30 and 40 percent, respectively. The paper suggests that, given these numbers, public health policy should focus more on preventive care and "promoting health." Initiatives like workplace wellness programs, which implement some of these principles, have been found to be cost-effective for the businesses that introduced them, according to another Health Affairs study published this February.
Despite the fact that we have probably been debating the wrong issue for the last year or so, the conservative view of responsibility has not won out. Regardless of the policy at hand, be it health insurance or preventive care (to which the Patient Protection and Affordable Care Act has devoted some attention), the principle of collective responsibility still holds: as a nation, we have a duty to ensure the health of our citizenry. Why? Personal responsibility only goes so far. In order to remain strong and productive, we must embrace the idea of our country as a Union, not merely a collection of individuals.
Yet Congress's power to "provide for the … general Welfare of the United States" (Article I, Section 8) is listed very shortly after the power "to pay [its] Debts," and indeed it is vital to the country's security and continued international prominence that our budget be in the black. Many of the possible effects of a governmental fiscal crisis (e.g., a run on the dollar and consequent US economic distress) have a detrimental impact on health: as goes employment, so goes mental health, with increased risk of suicide among the effects; and up goes stress, with higher risk factors across the board for illness. It is in these periods of distress that access to support for one's health is more needed than otherwise, and thus it is imperative to put the measures in place now, rather than later, when they are most needed. Preventive care is doubly important in this regard, because it reduces the future risk of poor health and consequently the need for assistance in difficult economic times. This thesis puts me in a bit of a bind, however. I advocate a measure that could enlarge the deficit, and consequently the debt, making it theoretically more likely that the greatest time of need for the system will come sooner. But recessions pass; the health of our population, and of our nation, must endure and improve. If that means more debt now, but a more productive country in the long run, capable of sustaining growth, that's a price I'm willing to pay.