Who Deserves Health Care? (a.k.a. Health Care is Hard)

Congressional efforts to repeal (and replace?) Obamacare seem to be on track to continue over the summer. The American Health Care Act (AHCA) passed the House May 4, 2017, and as written will gut Medicaid, defund Planned Parenthood for one year, and allow health plans to charge older, poorer people way more than they are paying now for health insurance.

You can read all sorts of news and opinions about why the House-passed AHCA bill is problematic if the goal of the bill was either to reduce health care costs for consumers or ensure access to health insurance coverage. But you might not read this: Late in February President Trump said health care is unbelievably complex – he was right and this is why.

Health care comes down to two questions that are easy to ask, but hard to answer. First, who deserves health care? Second, who should pay for it?

Question 1: Who deserves health care?

If you think everyone deserves health care, great. Then you can just jump ahead to the second question. However, to understand the current health care debate, it is important to know that many people, including many elected officials, think only certain people deserve health care. And when they say health care, they mean health care insurance.

For those promoting a “free market” approach, they support a system in which a person who “works hard” is rewarded with health insurance coverage. That is how most people in the U.S. get health insurance now. The problem is the definition of “works hard.” In 2014, 83% of people with a full-time job who made more than about $48,000 per year (400% of the federal poverty level or FPL) were offered insurance by their employer (see chart from Kaiser Family Foundation).

So one definition of “works hard” to the proponents of “let the free market decide” is well-paid full-time workers. Indeed, employer-sponsored insurance is the basic building block of the U.S. health care system. Historians will explain that in 1940 about 9 percent of the population had health insurance. In 1943, the Internal Revenue Service (IRS) ruled an employer offering the fringe benefit of health insurance could do so tax-free. As a result, in 1953, health plan participation jumped to nearly 65% of people. The IRS giving certain kinds of health insurance tax-free status hardly seems to be “letting the free market decide,” but we digress…

Besides full-time employees, who else worked “hard” enough to deserve health insurance? The second biggest group are Medicare enrollees. About 15% of Americans receive Medicare. But again, they “deserve” it, because every worker in the U.S. pays a portion of his or her paycheck to the Medicare fund. A person receives Medicare because they earned it – he or she either worked a certain number of years during their lifetime and paid into the fund, or their spouse did.

Yes, health insurance is different from health care. Emergency rooms are required by federal law to accept emergency patients. And community health clinics provide care on a sliding scale. So technically, everyone can get health care because we have emergency rooms and free health clinics.

Question 2: Who should pay for health care?

Even if your answer to question 2 is, “We should all pay!” it doesn’t necessarily make the mechanics of everyone paying any easier. If everyone pays, how do we do it? A flat tax for every person? A tax based on income? A tax based on how much health care costs where you live?

Should sick people pay more than people who are well? Should older people pay more than younger people? Should we all pay for a basic set of benefits, even those we don’t use? For example, should men have to pay for maternity care? Should young people have to pay for prostate exams or colonoscopies? Should middle-aged people have to pay for childhood vaccines?

As mentioned previously, we all pay for health care in the system we have today because our taxes go to support free health clinics and to cover the costs of hospitals who provide emergency care that is “uncompensated.”

Which brings us to why health care is so unbelievably complex. Each of us has our own experience with the system, and whatever we don’t like, we blame on “the system.” If your premiums have gone up in the past few years, you might blame Obamacare, but it is just as likely that your employer changed your health insurance plan so they could save some money for their shareholders. On the other hand, if you couldn’t get insurance before Obamacare because you had a pre-existing condition, you might credit Obamacare for that access.

One individual’s experience of health care or health insurance is not everyone’s experience, and your experience may or may not be because of Obamacare. But every story counts. Many elected officials are hearing from constituents that Obamacare is failing them, and that may very well be true. Other constituents are saying Obamacare saved their life, and that may also be true. Having an honest conversation about all the ways Obamacare helps and hurts people, and who deserves what, would be a better way to get to policies that would work. But that would be hard.