HEALTH CARE/Joan Retsinas

Defining 'Affordable': The Orwellian Dictionary

Define "affordable." The word crops up in proposed legislative solutions to the problem of the uninsured. Health insurance must be made "affordable," the mantra goes. But don't look to Webster's or the Oxford English Dictionary for guidance. Instead, look to an Orwellian Health Care Dictionary.

In this lexicon, "affordable" is charmingly abstruse: "what I think you could, should, and would pay."

The "I" is the legislative body that sets the standard -- not the "you" saddled with the tab.

Massachusetts legislators, for example, acted boldly. The state plans to nudge employers to cover more employees, to subsidize insurance for low-income residents, and to force middle-income residents to purchase health insurance.

One initial linchpin of the Massachusetts solution was an employer fee: employers (with more than 11 employees) who did not cover their employees would be assessed $295/worker annually. The bill-drafters felt the fee would not threaten companies‚ solvency -- or drive them out of Massachusetts. Yet "solvency," like "affordability," is in the eye of the beholder.

Businesses yelled "unfair." A sympathetic Gov. Romney listened, and vetoed the fee-part of the legislation. Legislators may or may not override the veto -- the battle over legislators‚ versus business's definitions of "affordable" has begun.

So too Wal-Mart has fought state proposals that would force it to insure more of its workers -- the glut of people now dumped onto state Medicaid rolls. Wal-Mart calls this burden "unaffordable." Wal-Mart is a private mega-corporation, with tentacles throughout the world. Maybe insuring clerks and stockers would force Wal-Mart to lay off workers, raise prices, retrench on expansion. Who knows? Certainly not the legislators who proposed what they felt was an affordable solution to the rising number of uninsured workers. Yet Wal-Mart's "affordable" is not synonymous with legislators'.

If businesses have their own take on "affordable," so do constituents -- those average working people that legislators spotlight in campaign advertisements. Legislators' "affordable" premiums don't jibe with constituents' definitions.

The details of the Massachusetts solution highlight the clash of definitions. Another linchpin is another mandate -- this one for middle-income residents. The state will require them to purchase "affordable" insurance. (Admittedly, without imposing "affordable" fees on businesses, it is not clear how "affordable" the state can make premiums.}

Kill-joy realists have argued that, whatever premium-reductions the legislature can bring about, few people will want to buy the policies. Analysts have discussed $325/month for an individual, more for a family.

Middle-income residents (defined as earning $30,000 or more a year) may have some wiggle room in their budgets to buy insurance. Legislators think so. Here, though, legislators confront the lexical shadings from "could," to "should," to "would." Perhaps a family "could" pay the "affordable" premium, if it cut back on junk food, alcohol, entertainment -- the stuff that legislators think other people should cut back on. And perhaps the family "should" pay for health insurance: on a personal level, to get preventive care and protect from catastrophic expenses; on a societal level, to spare the body politic the expense of uncompensated care. Yet "could" and "should" do not mean "would." Families may choose not to do what legislators prescribe. A state mandate that forces people to do something that they don't want to do is foolhardy. It invites legislative repeal.

Tax deductions -- a much-vaunted solution -- present the same dilemma. The deductions reduce the premiums -- but not enough to render the premiums "affordable" in the eyes of enough would-be buyers. Indeed, since those "affordable" policies are also "basic" (another term in the Orwellian dictionary), the policies leave the holder with expensive deductibles, co-payments, and non-covered expenses.

In an Orwellian world, legislators take plaudits for their "affordable" solutions -- even if those solutions solve nothing.

We live in that world of newspeak.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, June 1, 2006

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