The American Right to Health

 I’m just back from a terrific symposium on the right to health care at Boston University School of Law that was sponsored by the American Journal of Law & Medicine and chaired by Abby Moncrieff. Presentations by constitutional, health care and tax law scholars brought a very nice range of perspectives to the Affordable Care Act (ACA). The conference papers will appear in the AJLM in late spring; I’ll say a little now about mine, which builds on an earlier article in JAMA.

I’ve previously defended the commerce clause and taxing power justifications for the individual mandate to purchase health care coverage. But the chief threats to the rights in ACA lie not in any constitutional infirmities. Rather, they rest in defects of design. Even if the Supreme Court upholds the law, its basic protections may unravel in the future. As other public benefit programs have shown, it's difficult to sustain programs that serve only the poor. Universal programs like Medicare and Social Security fare much better than targeted programs like Medicaid, and ACA's access-to-coverage provisions are mostly aimed at the poor and near poor. If past is prologue, we need to worry whether the financially secure will support adequate funding for the coverage expansions over time.

A Medicare-for-all, single-payer reform would provide greater stability, but we know about the political obstacles to that path. A modified version of John McCain's 2008 health care reform proposal might be both effective and politically feasible.

As Alain Enthoven, Victor Fuchs  and the Committee for Economic Development have recommended, the federal government could give everyone a voucher that would be worth the full cost of the lowest-priced health care plan on the market. People could purchase more expensive plans, but they would have to pay the difference in cost between their plans and the low-cost plan. To protect against substandard plans, vouchers would be usable only for plans that met minimal federal standards for quality. To prevent cherry-picking, insurers would be required to take all comers, and preexisting conditions clauses would be prohibited. Under such a regime, health insurers would have a strong incentive to be the low-cost provider, and health care costs might be contained.

Comments

[Tung Yin]

"[T]he federal government could give everyone a voucher that would be worth the full cost of the lowest-priced health care plan on the market. People could purchase more expensive plans, but they would have to pay the difference in cost between their plans and the low-cost plan."

I understand the point that programs have more popular support when they have a broad base of beneficiaries, but I have a hard time seeing how it could be more efficient to tax me enough to provide benefits for the poor *and* for the voucher for me, and then give me the voucher back. I mean, I suppose there could be some efficiencies of scale, but more likely the extra transactions costs and government bureaucracy would eat away at those efficiencies and more.

[David Orentlicher]

If I'm understanding your point correctly, I think it's hard to predict efficiencies with health care systems. Medicare taxes you enough to provide benefits for the poor and for you after age 65, and it operates with lower administrative costs than does the combination of private insurance and Medicaid for persons under age 65. But even if a universal voucher sacrificed efficiency over a more ideal alternative, the advantages of a universal system (e.g., ensuring access to coverage) would compensate for the loss of efficiency.

[Tung Yin]

Hmm, but is it accurate to say that Medicare taxes me "enough"? Considering the massive unfunded liability in Medicare, it seems that Medicare does not come close to taxing enough to pay for what it's promising.

[junior prof]

Race-to-the-bottom plans are likely to fail (in terms of health care coverage) for many reasons that have been well documented by responses to previous pro-voucher arguments. One way to prevent sub-standard care (or, every time some treatment is needed, fighting with the insurance company over what is medically necessary) is to REQUIRE than all members of Congress (and their families) be enrolled in the proposed "bottom" or "base-line" plan. If it's good enough for the American people, it should be good enough for the lawmakers.

[Dora Romero]

Nice Post

[Pamela Averill]

For the increasing number of elderly Americans that needs special care, the government must give attention in all health care providers. They should know if they can still afford the expenses with tax for the health care services.