As a keen advocate of a single-payer health care system, I am perhaps an unlikely defender of the Affordable Care Act. But I support the ACA because it promises to remedy some of the most fundamental weaknesses in our current health care structure: It extends health coverage to 32 million presently uninsured Americans, and it emphasizes preventive care over costly crisis treatment. I believe the ACA is both workable and constitutional, worthy of validation by the Supreme Court and prompt implementation by the states.
To date, criticism of the ACA has focused most intensely on the individual mandate — the requirement that all Americans obtain health coverage even if they have to purchase a plan. Opponents insist that this offends individual freedom. But the ACA requires many other stakeholders in our dysfunctional health care system to take action as well, in the name of greatly expanding coverage. So the individual mandate is merely part of an integrated package of insurance reforms designed to enable people to get covered.
Some employers will be required to purchase coverage for their employees or pay a penalty. Insurers will have to offer coverage to all applicants, regardless of their health status. And taxpayers will subsidize the cost of coverage for those who cannot afford it. The critics, many of whom forget that conservatives designed the individual mandate in the name of personal responsibility, now decry the mandate in isolation, neglecting that the rules are designed to work in concert.
The individual mandate will drive down insurers’ costs (and the insureds’ premiums) by creating as large a risk pool as possible; without that critical feature, the other much more popular consumer protections could fail. Viewed in this way, the individual mandate is a modest incursion on individual freedom in order to achieve such large-scale social progress — a notion that most Americans accept. And Congress’ endeavors to solve significant national problems through ambitious social legislation generally have withstood judicial scrutiny.
As a legal matter, the individual mandate also falls well within Congress’ power to regulate economic activity that affects interstate commerce. Opponents of the mandate contend that lacking health insurance is “inactivity” and therefore beyond Congress’ power to regulate.
But again, this view is too nearsighted. Illness and injury are unavoidable. The uninsured eventually will seek and receive at least emergency care, which others (usually the provider or the taxpayers) will pay for. So while sitting on your couch without health insurance may not be an economic activity, engaging the health care system in a way that shifts the costs of care to others certainly is.
The 50 million Americans presently lacking health insurance exert an enormous effect on our economy; Congress found that the cost of providing uncompensated care was $43 billion for 2008 alone.
The ACA is not perfect, and it does not overcome every flaw in our troubled system. But it does make vital improvements and provides a framework for further advances. Those who reject the ACA because “this has never been done before” are cautious for the wrong reasons. Novelty itself is neither unconstitutional nor dangerous, and Congress has always innovated when tackling new problems. The landmark Civil Rights Act of 1964 was considered revolutionary at the time, yet who today can imagine an America where businesses and workplaces could lawfully exclude people based on race? Similarly, I believe that the American people will ultimately view the ACA as a courageous step toward solving another civil rights crisis: that of tens of millions of Americans without health coverage.
Rep. Jim McDermott (D-Wash.), a senior member of the Ways and Means Committee, trained as a psychiatrist and served in the Navy Medical Service Corps.
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