Monthly Archives: June 2015

King v. Burwell v. Everybody Else

This week, the United States Supreme Court is scheduled to decide the King v. Burwell case regarding the Affordable Care Act, often referred to as “Obamacare.” The kernel of this case is whether the people who drafted this legislation were manipulative or merely sloppy. The text of the bill reads that subsidies for purchasing health insurance are available to the poor only in the states that established their own healthcare insurance exchanges. This would exclude the populations of thirty-four states, including my state, Indiana, and without the subsidies many people who now are paying small insurance premiums would see their rates immediately jump to unaffordable levels. They would drop their insurance, and the whole experiment in providing widespread national health insurance would unravel.
The defenders of the legislation assert that Congress misspoke when it said that premium subsidies were only available to citizens with state-run exchanges, because what Congress meant was for the subsidies to be available to anyone who bought insurance from any exchange, state or federal. Opponents of the law say that it was worded this way deliberately, so as to try to force states to build exchanges so their citizens could benefit from the subsidies, and in any event the law should be enforced for what it says, not for what it was meant to say.
For what it’s worth, I think the Supreme Court will side with the defenders of the law, if only to avoid the bedlam that would occur if premium subsidies are taken away from millions of people. I am ambivalent about this outcome: I am not as fond of bedlam as I used to be, but I do think ultimately the Affordable Care Act is going to have to fail before it occurs to everybody that private insurance plans are a bad mechanism for financing the people’s right to health care.
Since we have already decided that people have a right to health care (which we have, if only because the emergency rooms have to take all comers), we ought to simply provide it as a public service, much as we do police and fire services. Aetna and Cigna and United Health add nothing of value to this process, they simply add overhead without solving any problems.
That is not to say that everyone should be satisfied with public health care, any more than they are all satisfied with public schools or public transportation. I believe in direct primary care as a model of private transactions to provide a kind of health care the public system will not provide. The common ground of public health care and direct primary care is that they are simple ways of paying for healthcare services that don’t need something as complicated as insurance subsidies.