HEALTH CARE/Joan Retsinas

Personal Responsibility in the Age of Obamacare

The gods of irony are chortling. Our country’s die-hard conservatives – the ones who loathe government, extolling the right of the individual to control his life — now must reckon with the Obamacare turnaround. They complain that the Affordable Care Act marks one more intrusion of Big Brother, or the Nanny-State, into their lives.

Yet the Affordable Care Act exalts personal responsibility.

Ironically, before the Affordable Care Act, the notion of personal responsibility for health insurance was spurious. Yes, there was no dreaded “individual mandate:” the government did not force anybody to buy insurance. But the people who were insured were for the most part insured because “somebody” enrolled them. That “somebody” could be an employer, or, if they were old, disabled, poor or otherwise eligible, government.

The legions of uninsured – roughly 43 million Americans – were not free-thinkers who chose not to enroll. The choice was moot: only a wealthy person could afford premiums on the “non-group” market. And few insurers would accept seriously ill people, even wealthy ones. In the private insurance market, before the Affordable Care Act, insurers could say “no,” as well as “wait.” In those glorious days, insurers routinely invoked “exclusionary” periods of no-coverage for “pre-existing conditions.”

In short, the “uninsured” were rarely responsible for their state. If “somebody” would have covered them, they would have been covered. And if that uninsured patient ended up in a hospital, via the emergency room, the hospital, spreading the cost through its pool of insured patients, would absorb the tab – though the patient would receive years of dunning letters from bill collectors.

Fast forward to today.

The Affordable Care Act – ironically – gives middle-income Americans genuine responsibility to choose. The person can enroll, or not. The decision is his. (Low-income people in states that expanded Medicaid will be included in Medicaid; in the 21 states that did not extend Medicaid, low-income people do not have the option of subsidies). Premiums for “non-group” policies, while high, come with subsidies depending on income.

Furthermore, the Act puts the responsibility for health-behaviors squarely on enrollees. Insurers can charge more for people who are obese: the 2015 surcharge is 30% of the premiums (up from last year’s 20%). The obesity-charge averages $1,620 per year. Smokers too will pay more: up to 50% more, though plans will include smoking cessation regimens. Insurers calculate premiums against risk; and those behaviors drive up costs. The Act puts the onus of paying on the people who over-eat, under-exercise, and smoke. The individual is in charge. Plans, though, can no longer bar sick people. Nor can plans institute exclusionary periods for “pre-existing conditions.”

Admittedly, the Act does not let individuals opt out of insurance without a penalty; but the penalty will often cost less than the premium for a “bronze” plan. Some people will pay as little as $325. And, again, individuals have a choice. Big Brother is not prima facie enrolling everybody (as with Medicare Part A).

What happens when a conservative, one who could afford the premium, chooses not to enroll?

Luis Lang – a Republican from South Carolina, the owner of a house worth more than $300,000, with a comfortable income – chose not to enroll. The fact that he was diabetic and a long-time smoker did not sway him. When the time came to enroll, he opted out. (“Who Should Pay To Save The Sight Of An Uninsured South Carolina Man?” by Ann Doss Helms, Charlotte Observer, May 13, 2015) As a self-employed contractor, he earned enough to pay his own bills – until two calamities coincided. The first: he suffered several mini-strokes, and ended with hospital bills that exhausted his savings. Second: his sight worsened, the result of diabetes. His retina was partially detached. He could no longer work.

To save his sight, he needed surgery. But the deadline for enrolling had passed. He had been uninsured his entire life: he hadn’t wanted it, hadn’t needed it. But once he needed costly care, and couldn’t afford it, he wanted insurance.

The couple assumed that “somebody” (a.k.a. the government?) would pay for his care in this emergency. He had exhausted his savings; he couldn’t work; without surgery, he would probably go blind. But South Carolina had not expanded Medicaid, so he wasn’t eligible for that insurance. He started a GoFundMe.com web page.

The ending for Lang, though not necessarily for others in a similar plight, was promising. “(S.C. Man Will Get Sight-Saving Surgery As Liberal Donors Chip In,” by Ann Doss Helms, Charlotte Observer, May 14, 2015). Thanks to newspaper coverage, coupled with cyberspace blaring, donors have contributed to fund the surgery.

Lang concedes not only that he should have taken better care of his diabetes, but that he should have bought insurance.

But thousands of others who want less government, don’t see the irony: they want freedom to determine their own fate; yet, when fate does not smile upon them, they look to Uncle Sam.

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

From The Progressive Populist, October 15, 2015

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