Health care reform: Is it ‘fair’?

A critique of the Affordable Care Act and a proposal for Maine

By Alice E. Knapp
Maine AllCare, April 24, 2012

Good people reasonably disagree on the merits of “Obamacare” (the federal Patient Protection and Affordable Care Act or “ACA”). Recent Congressional Budget Office estimates, however, project the ACA will leave approximately 27 million Americans uninsured in 2016 and beyond. While I might once have been persuaded that the law’s coverage gains justifies its failings, I now equate leaving 27 million Americans uninsured with having passed a law that freed but 90 percent of this nation’s slaves.

I view the ACA as symptomatic of this country’s corrosive slide into divisive, winners/losers politics. The law’s defenders have remained silent on why they believe it appropriate to extend through Medicaid expansions near free, comprehensive health insurance to millions of low income Americans while leaving millions of moderate income Americans similarly unable to afford comprehensive coverage to fend for themselves.

Visiting the Kaiser Foundation’s Health Reform Subsidy Calculator and entering two hypothetical, 52-year-old residents of a high-cost state like Maine illustrates the inadequacy of the ACA’s individual mandate premium subsidies and their arbitrary nature.

Using incomes based on the projected 2014 Federal Poverty Level (FPL), entering the first such resident with gross annual income of $46,021 (400 percent of 2014 FPL) yields a subsidy reducing that individual’s projected $750 monthly premium for the ACA’s “silver plan” to $364/month.

Entering the second resident at a gross annual income $115 higher at $46,136 (401 percent of 2014 FPL) yields no subsidy, leaving that individual to pay the full $750/month “silver plan” premium cost representing 19.5 percent of his/her gross income.

The high cost and coverage inadequacies of the private health insurance market leave both individuals facing upwards of $6,000 in annual, “silver plan,” out-of-pocket expenses (deductibles and coinsurance), on top of their premium expense, should illness or injury require them to use their insurance, and family coverage is exponentially more expensive.

This brings me to the language used by individual mandate proponents, which essentially vilifies the uninsured. Proponents’ “shared responsibility” argument suggests that those who fail to voluntarily purchase insurance in the individual market aren’t doing their part. I dare say most 5-year-olds could tell you that a system under which some get free government funded coverage; some get tax free, employer provided coverage; some get subsidies to help pay the cost of having to buy their own coverage; and the rest are left to pay the full cost of expensive, poor quality coverage, is not “sharing” responsibility for health care costs in any meaningful sense of the word.

Proponents also suggest the uninsured cost the rest of “us” when they get the care they need through the emergency room. Besides the fact that there are an awful lot of “us” who are not paying very much for our health insurance, this promotes the unconscionable myth that the uninsured receive all the health care they need through charity care.

Federal law requires hospitals only to “screen and stabilize” emergency room patients. If you present to the ER feeling poorly and are diagnosed with a malignancy that will kill you in time left untreated, do not expect a free course of radiation and chemotherapy, nor will patients with chronic conditions be sent home with free, refillable supplies of expensive prescription drugs required to stabilize their condition. Accordingly, some 3,000 uninsured Americans die prematurely each month for lack of access to necessary treatment. Countless more are thrown into bankruptcy as they desperately try to pay for needed care.

Language matters, and the scripted dishonesty of arguments defending the individual mandate mask the core unfairness of the ACA approach. A country that turns its back on some in need while providing handsomely for others is not one grounded in equal opportunity, and this shameful paradigm weakens the cohesiveness of our great nation.

American health care spending compared to that of countries with universal health care systems is more than adequate to provide coverage for all, and it is a national disgrace to continue on the path of irrational and grossly inequitable spending. National health care reform having once again failed millions of Americans, as the province of Saskatchewan once did for Canada, the time has come for Maine to lead the way by implementing a statewide single-payer health care system.

Alice E. Knapp, Esq., is a former health insurance regulator who during her tenure was appointed the first director of the Consumer Health Care Division within the Maine Bureau of Insurance. She lives in Richmond, Maine, and is a member of the board of Maine AllCare.