The rationalization and extension of the current market is financed by the other linchpin of the law: the mandate that we all carry health insurance, an idea forged not by liberal social engineers at the Brookings Institution but by conservative economists at the Heritage Foundation. The individual mandate recognizes that millions of Americans who could buy health insurance choose not to, because it requires trading away today’s wants for tomorrow’s needs. The mandate is about personal responsibility — a hallmark of conservative thought.
IN the partisan war sparked by the 2008 election, Republicans conveniently forgot that this was something many of them had supported for years. The only thing wrong with the mandate? Mr. Obama also thought it was a good idea.
The same goes for health insurance exchanges, another idea formulated by conservatives and supported by Republican governors and legislators across the country for years. An exchange is as pro-market a mechanism as they come: free up buyers and sellers, standardize the products, add pricing transparency, and watch what happens. Market Economics 101.
In the shouting match over the health care law, most have somehow missed another of its obvious virtues: it enshrines accountability — yes, another conservative idea. Under today’s system, most health insurers (and providers) are accountable to the wrong people, often for the wrong reasons, with the needs of patients coming last. With the transparency, mobility and choice of the exchanges, businesses and individuals can decide for themselves which insurers (and, embedded in their networks, which providers) deserve their dollars. They can see, thanks to the often derided benefits standardization of the reform act, what they are actually buying. They can shop around. And businesses are free to decide that they are better off opting out, paying into funds that subsidize individuals’ coverage and letting their employees do their own shopping, with what is, in essence, their own compensation, relocated to the exchanges.
Back when the idea of letting businesses and consumers pick their own plans — with their own money on an exchange — first floated around Washington, advocates called them “association health plans.” They, too, would have corrected for the lack of transparency, mobility and choice in local insurance markets by allowing the purchase of health insurance across state lines. They were the cornerstone of what would have been the Bush administration’s reform plan (had the administration not been distracted by other matters). After the rejection of “Hillarycare” in the mid-’90s, association health plans emerged as the centerpiece of pro-market, Republican thinking about health reform — essentially what would become Romneycare, extended via federal law to cover the entire country. So much for Mr. Romney’s argument that his plan in Massachusetts was an expression of states’ rights. His own party had bigger plans for the rest of the country, and they looked a lot like Obamacare.
But perhaps the clearest indication of the conservative economic values underlying the act is its reception by many Democrats. The plan has few champions on the left precisely because it is not a government takeover of health care. It is not a single-payer system, nor “Medicare for all”; it does not include a “public option,” a health plan offered by a federal insurer. It is a ratification of market ideas, modified to address problems unique to health insurance.
Mr. Obama’s plan, which should be a darling of the right for these principles, was abandoned not for its content, but rather for politics. Neither side is blameless here. The White House could not have been more ham-fisted in the way it rammed the bill through Congress. The Republicans in the House and Senate lashed back with a vengeance, sifting through the legislative colossus for boogeymen like “death panels,” and when they could not find things sufficiently alarmist, they simply invented them.
Clear away all the demagogy and scare tactics, and Obamacare is, at its core, Romneycare across state lines. But today’s Republicans dare not own anything built on principles of economic conservatism, if it also protects one of the four horsemen of the social conservatives’ apocalypse: coverage for the full spectrum of women’s reproductive health, from birth control to abortion.
Social conservatives’ hostility to the health care act is a natural corollary to their broader agenda of controlling women’s bodies. These are not the objections of traditional “conservatives,” but of agitators for prying, invasive government — the very things they project, erroneously, onto the workings of the president’s plan. Decrying the legislation for interfering in the doctor-patient relationship, while seeking to pass grossly intrusive laws involving the OB-GYN-patient relationship, is one of the more bizarre disconnects in American politics.
Obamacare draws fire from this segment of “conservatives” because it fortifies the other side in their holy war. Coverage for birth control and abortion has not been introduced by the law; but it has been neutralized economically across all health plans, as part of the plan’s systemic effort to streamline fragmented health insurance markets and coverage.
The real problem with the health care plan — for Mr. Romney and the Republicans in general — is that political credit for it goes to Mr. Obama. Now, Mr. Romney is in a terrible fix trying to spin his way out of this paradox and tear down something he knows is right — something for which he ought to be taking great political credit of his own.Continue reading the main story
Cambridge, Mass. — Politicians, particularly Republican candidates, among them Mitt Romney and Paul Ryan, like to emphasize the importance of individual responsibility – especially in railing against the Patient Protection and Affordable Care Act, known as Obamacare. Indeed, America was founded by individuals working hard to earn rewards rather than free-riding on the wealth of society.
At the Democratic National Convention this week, Democrats have defended and reclaimed Obamacare as one of President Obama’s signature achievements. (See Bill Clinton’s rousing endorsement last night.) But some Americans seem to be under the impression that the health-care law is a step away from personal responsibility, a step toward socialized medicine. That’s certainly the message they got from the Republican National Convention last week.
As knowledgeable columnists and health-care experts have pointed out, the opposite is the case. It is the pre-Obamacare system that involves free-riding: A patient who shows up in the emergency room is treated even if uninsured, but the hospital has to pass the cost on to the rest of us.
The abdication of personal responsibility is especially great to the extent that the medical community can attribute health afflictions to such risk factors as being overweight. (According to recent studies, every obese American adds 42 percent to medical costs, relative to those of normal weight.)
Obesity can sometimes be attributed to poor diet, lack of exercise, or other personal behavior. But researchers find it can also be genetic. Individuals with such risk factors or pre-existing conditions may not be able to get private insurance under the pre-Obamacare system – even if they don’t want to be free riders. The private health insurance plans often exclude them. In such a system, personal responsibility is sorely absent.
The Affordable Care Act (ACA) of 2010 was designed to solve this problem, with its “individual mandate” and its prohibition on excluding customers based on pre-existing conditions. Establishing personal responsibility is the reason why conservative think tanks proposed the idea of the individual mandate in the first place, and why Mitt Romney approved it as part of the health-care law enacted in Massachusetts.
All this has been said many times, of course. But new analysis exposes another disconnect between rhetoric and reality when it comes to personal responsibility in health care:
The states opposing Obamacare are the states where people are least likely to take personal responsibility for their health in their daily behavior.
Members of Congress from states with high incidences of obesity, poor eating habits, and poor exercise habits are much more likely to have voted against the health-care reform; those from states that rank high on physical fitness voted for it. The relationship is highly significant statistically.
Similarly, states that show signs of risky sexual behavior – high incidences of pregnancy among girls age 15-17 and the sexually transmitted disease chlamydia – tended to vote against the ACA. The same is true of states with high rates of smoking, drunk driving, and shootings.
Look at the graph above. The vertical axis shows how many of each state’s members of Congress supported the 2010 reform. The horizontal axis is a composite index of measures of personal responsibility. It is an average of a physical fitness index, which includes obesity and physical exercise, and a risky behavior index, which includes teenage pregnancy, drunk driving, and firearms assaults. These are patterns of irresponsible behavior that impose costs on others in two ways: directly (victims of a drunk driver) and indirectly (passing on hospital costs of treating the uninsured).
The vote was strongly against health reform among the congressional delegations from Mississippi, Alabama, South Carolina, Kentucky, Oklahoma, Kansas, Georgia, Tennessee, Texas, and Missouri. These tend to be some of the states with the highest rates of obesity, teenage pregnancy, drunk-driving fatalities, and firearms assaults in the country.
The reverse is true among many of the state delegations that voted for Obamacare: Colorado, Massachusetts, Connecticut, Hawaii, New York, New Hampshire, Minnesota, Rhode Island, New Jersey, and California.
There are outliers, of course, especially Utah. Perhaps this is because much of its population abide by Mormon teachings that promote healthy personal behaviors and prohibit risky ones.
Overall, however, states that voted against Obamacare, often in the name of personal responsibility, are those where populations exhibit the least individual responsibility when it comes to their own personal health behaviors, as identified by medical researchers.
In spite of the predominant GOP rhetoric, Obamacare is actually the right answer for those who believe in personal responsibility – not just in word but in deed as well. The pre-Obamacare system is not.
Jeffrey Frankel is the Harpel professor of capital formation and growth at the Harvard Kennedy School of Government.