The tax we all pay is the high cost of the unin­sured

Modern Healthcare - - CONTENTS -

Once again, the U.S. House of Rep­re­sen­ta­tives has voted for a re­peal of the Pa­tient Pro­tec­tion and Af­ford­able Care Act. Once again, the bill is go­ing nowhere, given the lack of votes in the Se­nate and a cer­tain veto by the pres­i­dent. And once again we ask: If the mantra is still “re­peal and re­place,” what would a pro­posed re­place­ment look like—specif­i­cally?

More than 30 times since the cur­rent Congress was seated in 2011, the House has voted to de­fund, dis­mem­ber or fully re­peal the re­form law. Fed­eral bud­gets ap­proved in the House to date also have ze­roed-out the ACA.

One of the lat­est at­tack lines against the law—fu­eled by the rea­son­ing the U.S. Supreme Court em­ployed to up­hold the con­sti­tu­tion­al­ity of the statute—tar­gets what op­po­nents are call­ing a “mas­sive tax in­crease” im­posed by the in­di­vid­ual man­date, which be­gin­ning in 2014 re­quires one to ac­quire health in­sur­ance or pay a penalty.

The jus­tices in their de­ci­sion last month de­clared the man­date mech­a­nism a tax. The Obama ad­min­is­tra­tion con­tends it’s a penalty. Which­ever word one wants to use doesn’t change the scope or mis­sion of the man­date, which as this page has men­tioned nu­mer­ous times is a con­ser­va­tive idea that Mitt Rom­ney whole­heart­edly em­braced as a linch­pin of the health­care re­form model he en­acted as gover­nor of Mas­sachusetts. If the pre­sump­tive GOP pres­i­den­tial nom­i­nee prefers to call the ACA’s man­date a tax, then he can’t le­git­i­mately es­cape call­ing the same ap­proach in Mas­sachusetts a tax.

That se­man­tics fight is a sideshow. What needs to be­come a larger part of the de­bate—more so than any tax as­pect of the in­di­vid­ual man­date, which will af­fect only a small per­cent­age of the pop­u­la­tion—is the truly mas­sive hid­den tax that has been im­posed on em­ploy­ers, pay­ers and pa­tients for a long, long time. It’s the cost of health­care ser­vices passed along throughout the sys­tem in the form of higher pre­mi­ums re­sult­ing from care for the unin­sured.

A sig­nif­i­cant por­tion of those costs comes from our fel­low cit­i­zens with the means to buy health in­sur­ance cov­er­age but who—for what­ever rea­son—opt not to do so. Of­ten it’s the young and healthy, see­ing them­selves as seem­ingly in­vin­ci­ble, who just don’t see the need for cov­er­age, maybe try­ing to prove their self-re­liance.

Un­for­tu­nately, the young do get sick. They can get very sick, re­sult­ing in drawn-out hospi­tal stays. Tragic ac­ci­dents oc­cur all the time, with dev­as­tat­ing in­juries usu­ally re­sult­ing in a long road to re­ha­bil­i­ta­tion. These sce­nar­ios can and do re­sult in mil­lions of dol­lars in care in very short or­der. When fam­ily re­sources run out, what’s the re­course? Those costs get picked up and passed along some­how, whether it’s through gov­ern­ment pro­grams or provider write-offs.

Other times, the lack of in­sur­ance is be­cause of cir­cum­stances be­yond one’s con­trol. The re­sult­ing in­ad­e­quate ac­cess to care im­poses an­other in­sid­i­ous tax on our sys­tem. When the unin­sured and un­der­in­sured are forced to forgo ba­sic care and rou­tine screen­ings, care de­layed can eas­ily re­sult in cas­cad­ing costs in the long term. And we all pay the price for that.

If not the in­di­vid­ual man­date, let’s hear some al­ter­na­tives on how to share the in­sur­ance risk more eq­ui­tably. And does any re­place­ment for the ACA just give up on the goal of ac­cess to health­care for all?

Last week’s House vote against the ACA prob­a­bly won’t be the last in that cham­ber this year, but any oth­ers will again be mostly sym­bolic. The only votes that will truly count are the ones that will be cast less than four months from now on Nov. 6.

DAVID MAY As­sis­tant Manag­ing


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