Judge’s Attempt to Strike Down the ACA Shows Why Health Care Reform is So Urgent
Last Friday, Judge Reed O’Connor of the Federal District Court in Fort Worth issued a summary judgement in a lawsuit known as Texas v. United States. Appeals are expected, but if the ruling were to stand, it would strike down the entire Affordable Care Act (ACA). That could end health care coverage for millions of Americans who get insurance through the exchanges or Medicare expansion.
The case, known as Texas v. U.S., lays bare the flaws of the ACA. Yes, the ACA has made health care accessible and affordable for many who would otherwise fall through the cracks, but it is a legislative, administrative, and economic mess. From the beginning, it has been at risk of collapsing from its own complexity. The new ruling shows more dramatically than ever why we need real health care reform.
A health care system to be ashamed of
The U.S. health care system is a national disgrace. Americans pay more for health care than people in other high-income countries, but we have far less to show for it. I’ve used this chart before, but here it is again, in case you missed it:
The problem isn’t that American hospitals and doctors don’t do good work.The Commonwealth Fund study on which the chart is based gives the United States high scores in that regard. Americans who are hospitalized for heart attacks or treated for cancer have survival rates well above the eleven-country average. U.S. doctors are rated better than average in discussing treatment options and following patient preferences. Preventive care also receives high marks.
Unfortunately, those strong points are more than offset by low marks for access and affordability. More American patients say they have problems paying medical bills. There are wider differences in access and health outcomes between low- and high-income patients in the United States than elsewhere. The high administrative costs of the fragmented U.S. health care system are a further drag on performance.
Insuring the uninsurable
The central problem facing would-be reformers is that we rely too heavily on individual and employer-sponsored insurance at a time when health care has increasingly become an uninsurable risk. For the uninsured and uninsurable, an illness or accident can mean financial ruin. That is not only true of low-income families, for whom even routine health care needs can be financially challenging. Health care costs are so unevenly distributed across the population that even middle- and upper-income families can’t afford the costs of major illnesses and chronic diseases. Just 5 percent of the population account for half of all spending, while the top 1 percent account for more than a fifth.
For households near the top of the spending curve — those with pre-existing conditions — conventional health insurance is not an option. Their medical needs fail to meet two traditional standards of insurability.
First, insurable risks must be the result of unpredictable chance. In reality, though, many individuals suffer from chronic conditions like diabetes that make them certain to require costly care for the rest of their lives, while others have genetic markers that make them medical time bombs from the point of view of private insurers.
Second, for a risk to be insurable, a premium that is high enough to cover the expected value of claims needs to be affordable for the insured party. However, commercially realistic premiums for people with costly chronic conditions could easily exceed their entire income.
The Affordable Care Act addresses these problems by forbidding insurance companies from canceling the policies of people who become ill and from refusing coverage, or charging more, for people with pre-existing conditions. However, those requirements make the ACA vulnerable to adverse selection — the temptation for healthy people to remain uninsured and buy into the system only when they become ill.
To combat adverse selection, the original ACA included the individual mandate, which forced everyone either to buy insurance or pay a penalty. That turned out to be the single most widely disliked feature of the law, so Congress cut the penalty to zero earlier this year. That action that undermined a key pillar on which the ACA rested. Whatever the legal and constitutional merits of Texas v. U.S., Judge O’Connor had economic logic on his side when he ruled that the individual mandate was an essential part of the ACA.
What to do now?
In the wake of Texas v. U.S., the first need is somehow to keep the ACA limping along until a real fix can be put in place. Hopefully, the necessary legal or legislative measures will be taken quickly. Beyond that, we need real, lasting reform.
One of the most talked-about proposals is Sen. Bernie Sanders’ Medicare for All. If enacted, that plan would move the United States to the top of the world performance chart in a single bound by providing universal first-dollar coverage for a wide range of health care services. That would outdo even countries like the U.K., Australia, and the Netherlands, where the government covers 70 to 80 percent of health care costs. However, the implications of the Sanders plan for the federal budget and taxes cause many observers to doubt its political feasibility.
In my opinion, reformers should look for some way to ensure universal, access to health care that still requires that people to pay a fair share of their own costs if they can afford to. In many previous posts, I have argued that the best way to do that would be a system of universal catastrophic coverage (UCC). Under UCC, the poorest families would get full coverage without deductibles, middle-class families would face out-of-pocket costs similar to those they pay under the ACA, and high-income families would be responsible for all but truly catastrophic medical expenses.
UCC has the potential to draw support from across the political spectrum. With a divided Congress on deck for January, that is a crucial consideration.
If you are a liberal, think of UCC as a scaled-down version of Medicare for All — one that guarantees universal affordable coverage while using high deductibles instead of new taxes as to ensure that the rich to pay their fair share. For my full pitch on UCC for liberals, read “Suppose Democrats Win on Medicare for All. What Then?”
If you are a conservative, think of UCC as a smarter way for the government to put the money to work that it now spends on Medicaid, Medicare, the ACA, tax deductibility of employer plans, and the rest of our messy jumble of programs. UCC offers all the scope any Republican could want for market-based incentives, transparency, and competition, without sacrificing the politically vital goals of universal accessibility and protection for pre-existing conditions. For details, read my post on Vox, “What a Good Conservative Health Care Plan Would Look Like.”
And, what if you are neither a liberal nor a conservative health care zealot? What if you just have the vague idea that all is not well, that we should do something … maybe … eventually, at the latest?
If you are in that category, Judge O’Connor’s ruling should be a wake-up call. The time to get moving on health care is now.
Based on a longer version posted earlier on NiskanenCenter.org.