The Arc of Justice in Healthcare


We all fear that phone call.  A medical report turns out the wrong way and life may never be the same.  When that call arrives we all have the same needs:  A doctor who cares, a place to go for treatment and the finances to afford what’s needed.  Starting on January 20th, some of my patients will join the 20 million whose lifeline to those fundamental needs becomes jeopardized.  

One of my patients facing this threat lost his job and health insurance during the 2008 recession.   Because he’s a diabetic and has a special needs son, no insurance company would sell his family a policy.   Why would they?   Diabetics and others with serious illnesses pose high risks for future health expenses.  Insurance companies make money by avoiding such risk.   After exhausting all the options, he sweated out 18 months with no coverage.   Finally, the roll-out of the California Exchange, funded by the Affordable Care Act (ACA), allowed him to buy an Anthem Blue Cross policy for his family.  

Do we really want millions of our fellow Americans to relive those nightmares?  We all benefit from the ACA’s fundamental commitment: That everyone deserves access to healthcare regardless of their ability to pay.  The policies guided by this principle moved us toward the achievement of universal coverage without changing the existing care of the majority of working families with employer based plans nor those with self-funded coverage.   

Two key features of the ACA make the difference for patients like mine.  The first, subsidized insurance exchanges, allows them to get coverage at prices negotiated for all.  This provides economies of scale in pricing and spreads the risks over a larger group, reducing the costs for higher risk individuals. The insurance premiums are subsidized by income to keep them affordable. 

The second key feature of the ACA, and the most controversial, is the individual mandate.  This provision requires individuals to purchase insurance or pay a fine.  Opponents consider the mandate an infringement on individuals’ freedom to decline coverage.  Despite the superficial appeal of the argument, no one in the United States actually declines coverage.  When uninsured individuals arrive in an emergency room with a severe illness or injury they receive treatment and the costs get passed on to the insured and to taxpayers.  Such “uninsured” individuals are free riders.  They enjoy catastrophic coverage paid for by others.  

Additionally, many free riders are young and healthy.  Their departure from the system, if allowed by a repeal of the mandate, would leave a sicker, costly population that would likely face unsustainable increases in premium costs.  We don’t allow individuals to opt out of auto insurance because it affects the public welfare.  Similarly, we should not allow free riders to opt out of health insurance and undermine the financial stability of the health system. 

The ACA isn’t perfect but almost everyone gets a fair chance at coverage.  Under the ACA the percentage of non-elderly uninsured fell from 18% to 10.5% as 20 million gained coverage.  Vice-President Elect Pence recently called for “an orderly transition…to a market based healthcare economy.”  The ACA includes market mechanisms, such as the markets for health plans on the exchanges and the markets for providers once insurance is purchased.  A purely free market approach, as the Vice-President seems to support, could never reach the level of coverage achieved by the ACA.  If markets are completely free, they price out individuals who lack sufficient resources.   Healthcare costs are so high that cutting off help from the ACA would deprive millions of needed coverage.   

As President-Elect Trump considers healthcare, he may want to consider the words of Martin Luther King, whose holiday precedes the inauguration by just four days.  “The arc of the moral universe is long, but it bends toward justice.”  Part of that arc includes our social justice system and the safety net that protects patients like mine.  Americans never have made a commitment to public welfare and then reneged on it.  Despite their party’s opposition to the creation of Social Security and Medicare, incoming Republican administrations never threatened to withdraw existing commitments.  Instead, they supported bipartisan efforts to improve the programs.   The Trump administration should do no less.  

Members of the Trump administration and their congressional allies also should consider that most of them and their family members will someday also receive that call.   They should not threaten to deprive fellow Americans of the healthcare security they would want for themselves. 

The arc of justice in healthcare has been long indeed.  We will soon learn whether the Trump administration will choose to defer the progress of the arc of justice under the ACA.  In the long run they cannot stop it. 

<em>Daniel Stone, MD is the director of a multi-specialty group in Los Angeles.</em>

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