I recently listened to the Affordable Care Act arguments before the Supreme Court. The legal arguments are very interesting, but I’m not a lawyer so I will try to stay away from them here. My bet is that the mandate will get overturned 5-4, community rating and guaranteed issue will fall with it but the vast majority of the rest of the act will stand, including the medicaid expansion. The arguments were fascinating, however, there is an argument that I wanted to hear and which didn’t come up much: healthcare is a continuum.
The supporters of the mandate have largely been allowed to frame healthcare in a binary way: You either get treated or you don’t. That allows them to paint a very clear picture of the healthcare market: “Everybody at some point in time will get sick and need healthcare. If they don’t have health insurance at that point, somebody else will pay for it. Since nobody knows when they will get sick we must mandate that they have health insurance all the time.” Some examples brought up during the arguments were people needing a heart transplant or being hit by a bus. In effect, what they are saying is that you don’t chose to purchase healthcare, that decision is thrust upon you by life events. All they are doing is regulating its financing.
This argument however ignores a very important point which is that healthcare can be purchased on a continuum of cost and quality. For instance, if you feel chest pains and walk into an ER, there are a wide variety of tests available to determine whether you have a heart attack or not. Some of those tests are relatively cheap. But if those turn out negative, more expensive tests might reduce the risk of a false negative further and further. So now the question is not: care or no care? The question is: What care and at what cost?
When looking at that world, many of the arguments by ACA proponents fall away. It is not true that our healthcare expenses are fully thrust upon us by life’s events. When feeling chest pains, some of us may opt for the full suit of scans, while others might chose to take a few extra days off with loved ones. Either choice might be sensible and there is no reason to assume that everyone would make one choice rather than the other. And yet, that is the choice ACA proponents assume away and wish to legislate away. That is fundamentally problematic, because while experts may know their topics quite well, the trade-offs between vacation time with loved ones and a slightly increased chance of heart attack problem detection, are not questions of fact. Those are questions of personal preferences.