The year-long GOP effort to repeal the Affordable Care Act (ACA) in 2017 revealed a real, principled divide in our country. Is healthcare a choice or a fundamental right? If it’s a choice, can I choose not to have it? If it’s a right, why do I need to pay for it?
While Democrats have always championed it as a right, one of the hardest realities for the party to confront is that healthcare continues to feel more like a requirement instead. And despite GOP failure to repeal the ACA on its whole, they succeeded in repealing one key provision in December 2017 when the individual mandate requiring Americans to own health insurance was to be stricken starting in 2019.
If healthcare’s a choice, can I choose not to have it? If it’s a right, why do I need to pay for it?
This was a major GOP win: reverting healthcare back to a choice as it was before the ACA would be the way forward. A person should be able to choose if they want health insurance and what they want it to cover — why pay for costly health insurance if you rarely see a doctor? In May 2017, former GOP Rep. Jon Chaffetz posited this analogy:
“Americans have choices…so rather than getting that new iPhone maybe they should invest in their own health care. They’ve got to make those decisions themselves.” — Former GOP Rep. Jon Chaffetz, May 2017
Unsurprisingly, he was harshly criticized for equating healthcare to an iPhone. But the underlying question he posed does have merit. Replace the iPhone in that analogy with rent — utility bills — or even food — and we come closer to understanding the GOP stance that healthcare be a choice.
In fact, President Obama once shared similar views as well. During his 2008 campaign, he expressed a more tactful analogy:
“If a mandate was a solution, we [would] solve homelessness by mandating everybody buy a house. The reason they don’t…is that they don’t have the money.” — President Obama, February 2008
For Obama, instituting a mandate or requirement to own healthcare would not solve healthcare. People simply couldn’t afford it in the first place.
These problems remain today. According to a 2015 Federal Reserve report, 47% of Americans live paycheck to paycheck. 46% couldn’t cover an emergency expense of $400. Compare that to the $695 penalty from the IRS for not owning insurance. Then compare that to the average annual premium of $2844. How can we expect the average American to be able to abide by a federal requirement to purchase healthcare?
This fact alone was enough evidence for the GOP to justify repeal. Many of their constituents simply could neither afford the penalty nor the cost of insurance. Exacerbating frustrations were ACA-mandated benefits for mental health and contraceptives that all health plans were now required to cover. But nearly a quarter of Americans disagree with mental health coverage, almost a third disagree with contraceptives coverage.
Why force taxpayers to not only buy costly insurance, but buy insurance that covered benefits their communities might not even value or use? Why not be able to choose?
And while headlines in 2017 blared warnings that 22 million people could lose insurance under the GOP bill, 15 million were projected to leave by choice as a result of this mandate being removed.
So is the GOP right? Is reverting healthcare back to a choice the path forward?
Yes, the GOP is right that healthcare has felt exceedingly expensive for many. Yes, costs need come down.
No, removing the mandate is not the way forward.
The mandate is not designed to help those who have difficulties affording insurance to buy it; it’s designed to protect those who were barred from it — those sicker, less healthy, or born with pre-existing conditions that are too expensive to cover.
Using Obama’s homelessness analogy, the ACA is less about forcing the homeless to buy homes, but requiring those with homes to provide for those without. In other words, can we mandate that the healthy with insurance pay more to cover the costs of those who can’t?
The answer is unsatisfying because the criticisms are fair: healthcare feels more expensive. And if we believe that all people deserve healthcare, it might have to be more expensive in the short-term if only to cover the costly medical expenses of those who are sicker and cannot afford it.
To move healthcare back to an individual’s choice forfeits this vision, and is ultimately only a short-sighted solution to rising healthcare costs. To enable individuals to buy plans that cover only what they care about is akin to buying into plans that don’t cover women’s health if you’re a man. Rather, we have to remember the role each and every one of us plays in our neighbor’s care, and look elsewhere in the healthcare system to reduce cost.
Ultimately, while the ACA does deserve its criticisms, its real crowning achievement was in galvanizing our nation to recognize healthcare as a universal right.
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