Healthcare, Androids, and Choice

As election season begins in earnest, conventional wisdom and the greenbacks emanating from the Koch brothers tell us that the Affordable Care Act will be central to the 2014 midterms. The Obama administration’s high-profile announcement of enrollment figures made clear that Democratic defense of the legislation—when it appears—will depend on out-spinning the GOP, replacing the Republican line that the health law has resulted in lost coverage and lost choice with a narrative about better, expanded coverage. Most Americans will likely react by muting the TV and retreating to whatever ideological corner feels most comfortable.

Before Americans throw up their hands, however, they might want to evaluate some of the assumptions underlying the Republican take on health reform, particularly its emphasis on choice. As in other features of GOP rhetoric, voters will find that what makes for a visceral ad does not necessarily gel with good policy.

Take the spot that the Koch-backed group Americans For Prosperity has begun running against vulnerable Democrats like Senator Kay Hagan of North Carolina. In all the ad’s iterations, the same actress declares that she detests political ads, but that “healthcare isn’t about politics…it’s about people.” She then accuses the ACA of causing millions of people to lose “their health insurance” and to lose access to “their own doctors,” and asserts that Americans are now “paying more, and getting less.”

A number of elements of the ad are noteworthy. For one, after the actress mentions “people,” the viewer expects her to say, “But, as an android, I can’t know what people want.” (Perhaps the Obama administration should enlist the androids of Janelle Monae’s artistic world as a corrective in its own ads.) More to the point, the spot progresses steadily from well-spun but accurate claims that the ACA’s minimum coverage requirements resulted in cancelled plans and changes in provider networks to the essentially untrue assertion that Americans are getting less bang for their buck in healthcare.

Some of this rhetoric about choice, then, is grounded in the facts. Because the ACA sets a number of basic services that all plans must cover, it led insurers to cancel plans that covered very little. People who could not get replacement plans with the same provider network, then, may have lost their preferred doctor. But the bit about “paying more for less” does not reflect reality; even those with higher premiums benefit from minimum coverage requirements, and with the law’s subsidies and prohibitions on discrimination based on health status, many Americans will pay less.

Even if some GOP facts are correct, however, the implications drawn from them could not be more wrong-headed. Take the idea that “stopping Obamacare” would restore choice to the American healthcare system. As Dr. Ezekiel Emmanuel, one of the law’s architects, pointed out in the New York Times, the presence of restrictive provider networks was a mainstay of the pre-reform healthcare landscape. This is because they perform some useful functions, like allowing insurance companies to negotiate for lower prices. ACA or no ACA, people will still have to deal with the doctors their insurers want them to see.

A larger problem with the GOP’s obsession with “choice” is that it presents choice, narrowly construed, as the primary metric by which to measure health reform. But what about access, or that other Republican bugaboo, cost? Before the ACA, Americans not only had limited choices in the form of selective provider networks, they also had less security even with those restrictions—no minimum coverage requirements, no limit on out-of-pocket costs, and no protection if their insurance company decided they had a pre-existing condition.  In terms of cost, the experience of New York’s insurance exchange has been a case-study in how limiting some choices can increase participation in the insurance market, increase competition, and reduce premiums.

Of course, none of this argument is meant to obscure the hardships that shifts in the insurance landscape can cause to families, or even the need for some course-corrections to ameliorate those burdens. But the real question is, how do we achieve universal, quality healthcare in the United States without the sort of minor restrictions stemming from the ACA—restrictions that differ little from what they were pre-reform and come with numerous improvements?

Let’s ask the self-proclaimed experts. In 2009, Representative Paul Ryan and Senator Tom Coburn, among others, proposed the “Patients’ Choice Act” to provide “universal and affordable health care for all Americans.” As the Washington Post’s Dylan Matthews noted, “it looked lot like Obamacare,” including state exchanges featuring plans with “standard health benefits,” bans on refusing coverage to those with preexisting conditions, what one economist called “a soft individual mandate,” and a tax credit like the ACA’s subsidy. To summarize, the Republican’s choice-centered health plan included the features of the ACA that have drawn ire for limiting choice, and the same benefits in return.

So the next time you see the Koch brothers’ android urging you to “stop Obamacare,” remember that healthcare is indeed about people, and that the same people who would have you believe that the ACA is a choice-limiting monstrosity had earlier reached the conclusion that its provisions were the best way to ensure both “patient choice” and “universal and affordable health care.”

Nelson L. Barrette ’17, is a Crimson editorial writer in Thayer Hall.