Most liberals and Democrats admit that the rollout of the Affordable Care Act has been a mess. How serious this is for the long-term success of the law is a matter of debate, but no one thinks this has been anything other than a rocky start. The most visible problem, of course, has been the all-but-non-functional healthcare.gov website, which has prevented people (how many is uncertain) from signing up for insurance plans under the new federal exchange. But more recently the focus has shifted to the architecture of the law itself–specifically changes to the individual insurance market which have resulted in people having their existing policies cancelled and, in at least some cases, seeing the amount they will have to pay to get new policies go up.
There are good wonky liberal responses to this–Jonathan Chait provides a nice overview here. The short version is that two groups–those without any insurance at all and those who purchased individual insurance–were always going to be the ones most affected by the ACA. For the former, the effects were virtually all positive: they would either be able to afford insurance on the exchanges, possibly qualifying for subsidies to help, or they might fall under expanded Medicaid eligibility. In the case of the latter group, things are a bit more mixed. Many of these people would find that they could now afford policies that were cheaper and/or better than what they had before. But at least some of these people (no one seems to know for sure how many) would end up paying more for policies comparable to what they had before. This is the much-vaunted “sticker shock” we’ve been hearing about.
As Chait explains, the reason for this is relatively simple: the whole purpose of insurance is to put people into risk pools in order to spread risk (and hence cost) around. Thus in any risk pool, those people with lower risks (in this case, the young and healthy) are going to end up “subsidizing” those with higher risks (the old, the sick, etc.). So people who were able to get policies for less, because insurers could discriminate based on your health history, may now find themselves paying more because they are in a pool with people who previously would’ve had to pay more, or wouldn’t have been able to get insurance at all. The very same principle operates in the employer-based insurance model, which is how most Americans currently get their insurance. People whose age and health vary widely are grouped into a single risk pool, with the younger, healthier people effectively subsidizing the older and less healthy.
From a certain point of view this all sounds horribly unfair. But only if you take an ultra-individualistic, short-term view of fairness. As David Kaib nicely explained in a post yesterday, the concept of social insurance rests on a sense of social solidarity. We spread risk around because we want everyone, within limits, to be taken care of and have a shot at a decent life. All wealthy societies have implemented forms of social insurance, including the U.S., despite our individualistic rhetoric.
The notion of solidarity rests not only on concern for our fellow citizens, but also a more realistic understanding of our own self-interest. Social and political philosophers like Alasdair McIntyre, Martha Nussbaum, and Susan Moller Okin have pointed out that much of the Western political tradition assumes that the typical or normative human being is a healthy, independent, male individual, and this has distorted our concepts of justice. In reality, all of us find ourselves, at some point in our lives, dependent on others, whether as infants and children, or because we get sick, or because we get old and frail and lose our minds. We are “dependent rational animals,” in McIntyre’s suggestive phrase. Vulnerability and dependency are instrinsic to the human condition.
This means that even if you are a young, healthy person, you will, inevitably, be an old or sick person. And when that happens, younger, healthier people will be caring for you. Social insurance is simply a way of institutionalizing this, making it less ad hoc and subject to chance.
It should be obvious that these principles are congruent with Christian ethics, which enjoin care for the neighbor, respect for parents, and justice for the poor, the widow, and the orphan. Moreover, the doctrines of original sin and unmerited grace emphasize our common human lot and fact that none of us can save ourselves. Conservative Christians sometimes argue that social insurance is not a proper responsibility of government but that relief for poverty and sickness should come voluntarily from churches and other non-governmental entities. But there’s very little in the Christian ethical tradition per se to support such a restrictive role for government; this view owes more to libertarian conceptions of the “night-watchman state” than anything specifically Christian.
Unfortunately (from my perspective), the U.S. is still caught in the debate over whether the government has a proper role in ensuring economic security for all its citizens. This distinguishes us from most European social democracies, where the debate is more about the means by which the government should do this, the precise levels of expenditure, etc. During the last election, the Democrats emphasized solidarity and interdependence to some extent (e.g., the president’s (in)famous “you didn’t build that,” and in some of the speeches at the Democratic National Convention), but American political discourse still seems largely driven by notions of individual rights and deserts. We need a stronger culture of solidarity to underwrite a commitment to social insurance, and thus the possibility of human flourishing for all.