WHO DEFINES HEALTH CARE FREEDOM?
No sugarcoating it: The GOP plans would pit freedom of choice against freedom from fear
What is the health care debate all about? Freedom. Specifically two different conceptions of freedom. One is freedom to buy what you want. In this view, the country is a collection of 325 million individuals, and freedom is everyone pursuing their lives without interference. The other is freedom from worry. It views America as a community, and freedom is knowing you can get help when you are sick and in need.
The difference is illustrated by one of my late patients, Dot Ahern, who had chronic myelogenous leukemia. She was kept alive and continued to actively work as a substitute teacher in the public schools of Worcester, Mass., by a medicine that cost tens of thousands of dollars every year. While comfortably middle class with a suburban house, she could not afford to pay for that medication out of her own salary.
Fortunately, her insurance paid. And her insurance premium was affordable. Why? Because other people were also buying health insurance, but they did not need tens of thousands of dollars in drugs or medical services.
THE PRICE OF CHOICE There is no way of sugarcoating it: The other people buying insurance were subsidizing Ms. Ahern’s care. Eventually, when they had an illness or accident requiring expensive medical care, that in turn would be subsidized by others. Ms. Ahern’s freedom to have affordable health insurance required other people to buy it.
That is how insurance works. Many people pay premiums for car, homeowners or flood insurance, but few use it in any given year. Those who don’t file claims are subsidizing those who do.
But what if these other people said they wanted the freedom to buy insurance that covered fewer services, and therefore had a lower premium? House Speaker Paul Ryan says the GOP approach is better for them: “Freedom is the ability to buy what you want to fit what you need.”
If many people decide to buy insurance that covers less, however, Ms. Ahern will have to pay more — lots more — for her insurance. And if this process continues, her premiums will eventually be unaffordable — or, more precisely, there will be no insurance. She alone will be responsible for paying tens of thousands of dollars for the drugs that keep her alive and working.
The freedom Ryan lauds is the freedom of individuals to buy only what they want at that very moment, and not have to pay for maternity care or mental health care or dental care for children, or for Ms. Ahern’s expensive cancer drugs. It means that people who are older or have cancer, Parkinson’s disease or diabetes will be priced out and lose the freedom from fear that comes with having health insurance.
The fundamental and inviolate law of health insurance is that the only way to ensure that freedom from fear is to “require” other Americans who are unlikely to use much health care to buy health insurance, too — and not just insurance that covers the few services they will use. Freedom not to have health insurance for some necessarily, inescapably means the loss of freedom to have health insurance for others.
OBAMACARE OR MEDICARE This “requirement” can be accomplished in two ways: We can keep the Obamacare approach of requiring everyone to buy health insurance and subsidizing those with lower incomes so that they can afford the premiums. Or we can adopt the Medicare approach — the government provides all Americans with a minimum health insurance package and they can buy coverage for additional services, such as drug cov- erage, at subsidized rates.
There are no other options that work. Charging much more to people who don’t buy insurance immediately is not sufficiently effective. Besides, paying a penalty for not buying insurance looks a lot like the Obamacare mandate that Republicans deride.
The basic choice on health care reform is this: We can give freedom to young healthy people to buy what they want and deny the Ms. Aherns of this country freedom from worry about whether they can afford health insurance and their lifesaving drugs. Or, we can recognize that at some point in our lives, most of us will be like Ms. Ahern — we will contract an expensive illness and need other people to help us by keeping health insurance affordable.
Unless you are invincible, and will never get sick or in an accident and need a doctor or hospital, you too will need the help of others, and the freedom that comes with knowing you will be able to count on them.
Ezekiel J. Emanuel, an oncologist, a venture partner at Oak HC/ FT and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, advised the Obama administration on the Affordable Care Act. His new book is Prescription for the Future.