To Your Health

March 23, 2010

Two nights ago, like many in the US, I opened a bottle of wine to celebrate our embarrassing milestone of having finally joined the rest of the industrialized world in passing healthcare reform. Today it’s law. Yay us.

FWIW, I likely would’ve opened the wine anyway, but passage of healthcare reform somehow made that wine twice as enjoyable. Plus, that I would’ve opened the bottle of wine anyway lends all the more credibility to my reported elation, as I wasn’t in it for the wine. (Or something to that effect.)

As anybody who has been following this issue knows, getting here has been no easy undertaking. Even as you read this, the nattering naybobs of nincompoopitude are donning their tri-cornered hats and reenacting a fantasy era in American mythology, albeit this time with beer guts and bulging Lloyd Marcus (?) t-shirts. Now that challenges to the new law are coming out of the woodwork, it raises the important question: what does this terrible, awful, no good, very bad healthcare bill do?

If, for some reason you haven’t seen this yet, here’s a list of the “Top 10 immediate benefits” from Representative John B Larson. And here’s a nice, slightly harder to read, overview of some of the immediate benefits.

  1. Prohibit pre-existing condition exclusions for children in all new plans;
  2. Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;
  3. Prohibit dropping people from coverage when they get sick in all individual plans;
  4. Lower seniors’ prescription drug prices by beginning to close the donut hole;
  5. Offer tax credits to small businesses to purchase coverage;
  6. Eliminate lifetime limits and restrictive annual limits on benefits in all plans;
  7. Require plans to cover an enrollee’s dependent children until age 26;
  8. Require new plans to cover preventive services and immunizations without cost-sharing;
  9. Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions;
  10. Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs.

Now what about any of these is so hard to understand? Let’s go through a few of them…

Is it hard to understand that children should not be excluded from insurance because of pre-existing conditions? If it is, then apparently you haven’t thought much about what that would mean, or what possible justification there might be, to exclude a child from healthcare. Oh, sure, maybe it’s good for the insurance companies. That’s possible. Maybe it even keeps premiums lower for everyone else. By excluding the sick, insurance companies don’t have to spend as much on their customers, and so therefore every other customer benefits… But that couldn’t be what we mean by ‘good’. A ‘good’ insurance program is one that offers insurance to those who need it, not to those who don’t.

In fact, it also violates a fundamental principle of interpersonal justice — that a rule should be impartially applicable and universalizable. When we’re talking about kids, there aren’t even any moderately plausible defeaters of such universalizability. There can’t be any justification that appeals to bad lifestyle decisions, as maybe (maybe!) there are when we’re talking about people who smoke three packs a day for twenty years or indulge in the ridiculous and tasteless gluttony of a twice-daily bag of microwave popcorn.

Even in the case of adults who engage in such self-destructively stupid behavior, I think there’s reason to include them in our insurance pool too, just as two and three propose. Why? Because  it expands agency, it allows each one of us the freedom to make stupid decisions without fear that our stupid decisions will rob us twice — once of our health, and then of our family’s bank accounts. Good health is reason enough to stay healthy. We don’t need an extra reason — like going bankrupt — to stay out of the hospital. Hospitals are miserable places.

So that covers one, two, and three.

Four is a fairness and a reasonableness reason. The donut hole should’ve been closed a long time ago. It doesn’t make any sense to have seniors paying for the two-thousandth through the six-thousandth dollar of their medications.

Five is an efficiency reason, and should be clear to any small business owner who has had to compete with the big Schlockmarts on the block. It’s good for small business.

Six is an arbitrariness reason related to one, two, and three, but also to the point that, effectively, lifetime limits kick in when you really need insurance. If lifetime limits are universalized in any way, their universalization obliterates the purpose of insurance in the first place. Suppose a lifetime limit of $15,000. That’s obviously too low, but there are two ways of understanding its too lowness: either it’s too low because enough people won’t participate in the insurance pool to make the pool work; or it’s too low because it won’t cover people who really need insurance. When lifetime limits are in place, they shift the reasoning to that of the first sort. Insurance, so far as I can tell, should be in place to cover those who need it.

Seven just moves the logic into the realities of the 21st century, enabling our children to explore and learn beyond college, to maintain healthcare in a way that doesn’t force them at 21 into the workforce when they are ill-prepared and still trying to gain a foothold on a lifelong career.

Eight further removes obstructions that may have been causing people to second-guess preventive medicine; where nine and ten open the windows to allow a little disinfecting transparency.

Challenges from the right will likely come in the form of misinformation, but you should always be able to point to these ten immediate effects in order to counterbalance any death panel bullocks. Just ask those who object to justify repealing one of these ten benefits, and don’t rely on the spurious cost considerations. Those really oughtn’t to play a role here.

Arguably, the more problematic challenges come in the form of appeals to the US Constitution. Randy Barnett at the Washington Post offers this pessimistic overview of the impending constitutional challenge to the bill. He closes with a nod at Bush v. Gore, winking cynically that we may well witness another castration of justice at the hands of the political supremes. Fortunately, legal scholars like Jack Balkin are on the job, nicely contextualizing the plausibility of this claim. Here’s a taste:

The most likely constitutional challenge will be that the individual mandate to purchase health insurance is unconstitutional because it forces people to buy insurance. Barnett omits to mention in his op-ed that the mandate is actually structured as a tax: if you don’t buy insurance, you are assessed a tax for each month you fail to pay premiums. Barnett argues that individual mandate must be unconstitutional because the government can’t require people to do anything; however, the government can make you pay taxes. It does so every year. Congress pretty clearly has the power to pass such a tax under its powers to tax and spend for the general welfare. This is an easy case for constitutionality.

Finally, permit me this minor bit of crankiness, directed primarily at those who object and based loosely on a line that I encountered far too often just a few years ago regarding the war, quite possibly from the very same party-nincompoopers who are now complaining about this healthcare bill:

Don’t like the recent legislation? Move. Move out of the country. Leave the United States. Don’t let the door hit you on the way out. Go some place you’d like better, where they don’t have widespread health coverage.

Employing this strategy, I’m afraid, will limit your options considerably. You won’t be able to move to our nearest English speaking neighbor to the north; and don’t count on moving to any country in Western Europe either. If you’d like to stay in the Americas, maybe to retain the misnomer appellation “American” that really seems to butter your buns, you also can’t move to places like Argentina, Brazil, Chile, Costa Rica, Mexico, Panama, Peru, Uruguay, or Venezuela. Matter of fact, you’d have to move pretty far down the list of even developing nations to get to a place that would suit your uniformed ideological predilections.

I daresay, motherfuckers, the world was looking a whole helluva lot warmer and sunnier today, and at least on this occasion, I don’t think it has anything to do with global warming.

Congratulations America.


  1. Thanks- interesting article. My education on US healthcare continues. As a Brit, what seems particularly strange about the debate is the strength of feeling on the ‘anti’ side: how large chunks of the US population seem to be so stridently against something that, well, looks like it should benefit large chunks of the US population.

    What am I missing?

  2. Unfortunately, you’re not missing anything. That’s the way politics seems to operate in the United States. There was a book a few years back called “What’s the matter with Kansas?” that I think basically picked up this point. I’m fairly that sure I don’t agree with everything in that book, and maybe even with the underlying premise. The basic thought is even more convoluted than the author suggests:

    It’s not “Why do middle income Americans persistently vote against policies that are in their own self-interest?”

    It’s more perplexing: “Why do middle income Americans persistently vote against policies that are in their own self-interest in the name of defending their own self-interest?”

    It would be one thing if the US voter was voting against her self-interest for other reasons — maybe she feels that it’s not fair to the rich, say; or maybe it’s not right — but the US voter persistently claims that these policies that are quite clearly in her own interest are not in her own self-interest.

  3. My problem with this bill is that it appears to violate the constitution. The “trick” of providing a “choice” to buy health insurance – backed up by a penalty of 2.5% of gross income (see table below, taken from President Oboma’s press release)could be used to force citizens to purchase anything (if constitutional). What a great way to fix the economy. Give everybody the “choice” to buy a new house, new car, new appliances, you name it – and if you “choose” not to – charge the taxpayer 2.5% of their income.

    The problem with this idea – Congress has the power to regulate commerce between the states – but not the power to force anybody to engage in commerce. An individual decision not to buy something cannot be regulated by Congress (as I see it).

    Because 13 states have sued on this issue – I am sure we will find out whether it is constitutional.

    Year Penalty Percent of Income*
    2014 $95 1%
    2015 $325 2%
    2016 $695** 2.5%
    * In lieu of the flat penalty if greater
    ** Indexed for inflation thereafter

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