Michael R. Strain is a resident scholar at the American Enterprise Institute.
Say conservatives have their way with Obamacare, and the Supreme Court deals it a death blow or a Republican president repeals it in 2017. Some people who got health insurance as a result of the Affordable Care Act may lose it. In which case, liberals like to say, some of Obamacare’s beneficiaries may die.
During the health-care debates of 2009, Rep. Alan Grayson (D-Fla.) brought a poster on the House floor: “The Republican Health Care Plan: Die Quickly.” In the summer of 2012, when Obamacare was threatened by a presidential election, writer Jonathan Alter argued that “repeal equals death. People will die in the United States if Obamacare is repealed.” Columnist Jonathan Chait wrote recently that those who may die are victims of ideology — “collateral damage” incurred in conservatives’ pursuit “of a larger goal.” If these are the stakes, many liberals argue, then ending Obamacare is immoral.
Except, it’s not.
In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals — including more cash for other programs, such as those that help the poor; less government coercion and more individual liberty; more health-care choice for consumers, allowing them to find plans that better fit their needs; more money for taxpayers to spend themselves; and less federal health-care spending. This opinion is not immoral. Such choices are inevitable. They are made all the time.
Consider, for example, speed limits. By allowing people to drive their cars at speeds at which collisions result in death, our government has decided that the socially optimal number of traffic fatalities is not zero. Some poor souls die: There were more than 30,000 traffic fatalities on America’s roads in 2013. If we didn’t accept that risk, we’d lower the speed limit to a rate at which accidents simply don’t kill, such as 10 mph. Instead, we’ve raised it periodically over the years, and you can now go as fast as 85 mph on a few highways.
It is tragic that thousands of people die each year in car crashes. At the same time, there are huge (if dispersed) benefits to a 70 mph speed limit over a 10 mph limit: a transportation sector that can deliver goods quickly across the country; increased productivity, because millions of commuters can spend more time at work than in transit; and more time at home with our children.
Likewise, thousands of people die in homicides in the United States every year. We could reduce this number substantially, but we have (at least implicitly) decided that the costs — financial and otherwise — of more intrusive monitoring, additional policing, stricter sentencing and other, harsher measures are not worth the benefit. (Though we should continue debating whether marginally higher costs are worth marginally fewer deaths.) A sentry on every street corner and a government-monitored camera in every private room and hallway in America would significantly lower the homicide rate. But I wouldn’t make that trade-off.
How do policymakers decide such things? In the deepest sense, every human life is inestimably valuable. But in a fallen world where trade-offs are inevitable, public policy can’t treat each life that way.
First, public policies — such as speed limits, gun-control measures and many others — usually affect the probability of death, rather than resulting in any specific person’s death. So economists can estimate the amount of money people are willing to pay to avoid slight increases in the probability of dying and then use that estimate to calculate the “value of a statistical life” (VSL).
This measure “serves as the basis for the standard approach used by government agencies to establish monetary benefit values for the predicted reductions in mortality risks from health, safety, and environmental policies,” economist W. Kip Viscusi, a leading VSL expert, writes in a recent paper. He says, based on an analysis of government policies, that the United States places the value of a statistical life between $6 million and $10 million.
“The Food and Drug Administration’s 2011 regulatory impact analysis of labeling for bronchodilators to treat asthma used a VSL of $8.1 million, the Occupational Safety and Health Administration’s 2011 analysis of general working conditions in shipyard employment used a value of a statistical life of $9.5 million, the Food Safety and Inspection Service’s 2011 analysis of inspection and test result procedures used a VSL of $7.3 million, the Federal Aviation Administration’s 2012 analysis of flight crew duty and rest requirements used a VSL of $6.6 million, and the U.S. Environmental Protection Agency’s 2012 regulatory impact analysis of new source performance standards for petroleum refiners used a VSL of $9.8 million,” Viscusi writes.
This approach is not without controversy, but the VSL is a key factor in many decisions made by federal agencies. And it shows that trade-offs between benefits and costs, including deaths, are routinely made by government agencies. “Policies for which the net cost per expected life saved exceeds the VSL will not pass a benefit-cost test,” Viscusi writes.
But most Americans — including their elected representatives — do not think this way when they debate major policy changes. The legislative process in some ways is simpler, but it is an outcome of a raucous, messy, imprecise and reductive political process. That’s why arguments sound like “repeal equals death.”
Repealing Obamacare could — although wouldn’t necessarily — result in more people dying. But it clearly would not be immoral.
Consider this question: Should society have as its goal that the government prevents all deaths from any health-related ailment other than natural causes associated with ripe old age? The notion is absurd — to both conservatives and liberals. There are limits to the proper amount of scarce resources, funded by taxpayers, that Washington should redirect toward health care.
I doubt Obamacare supporters would argue for a society that spends half or two-thirds of its national income on health care in an attempt to ensure that every person with a treatable disease or injury avoids death. Liberals aren’t arguing for a paramedic on every street corner and a nurse in every private building. Liberals and conservatives agree that in a world of finite resources, some people are going to die of potentially treatable illness and injury.
It wasn’t long ago that conservatives were the ones injecting too much talk of death into the health-care debate. Sarah Palin urged Americans in 2009 to oppose the “death panels” — in reality, end-of-life counseling — in the Democrats’ health-care bills. Liberals argued that this discussion was unhelpful. They were right.
A better discussion, both then and today, is about appropriate social goals and the resources required to meet them. Among the many needed reforms to our health-care system, one should be that we move closer to universal insurance coverage — on this point, the president is correct. But what should universal coverage look like? It requires a nuanced answer.
The insurance system should be designed to financially protect people from low-probability events, rather than provide comprehensive coverage for all health events, as Obamacare envisions. People should be free to pay for whatever care they like, but the government should not take money out of their paychecks to subsidize small-scale events that will happen with near-certainty (such as my annual sinus infection) or truly elective procedures (some states choose to cover acupuncture and most cover chiropractic care under their interpretations of the law). Instead, universal coverage should concern itself with the catastrophic expenses associated with serious medical events that will affect a minority of the population. People who can afford such coverage should be incentivized to purchase it, and those who can’t should receive a government subsidy to do so.
Such a plan would lower premiums and offer more choice than Obamacare. It would require less spending, fewer tax dollars, less coercion and less regulation, leaving more money for other important government programs or for taxpayers to spend as they wish. A few conservative plans along these lines already exist, and not just among economists and think tank scholars. GOP Sens. Richard Burr (N.C.) and Orrin Hatch (Utah), along with former senator Tom Coburn (R-Okla.), have a well-developed, well-known proposal, the thrust of which has growing support among many conservative intellectuals and members of Congress.
The Burr-Coburn-Hatch plan would repeal the Affordable Care Act, including the individual mandate to purchase insurance, and leave the current system of employer-sponsored coverage largely in place. It would cap the tax preference for employer-provided coverage (though only for extremely generous plans) and use the revenue to provide a tax credit for people who don’t get their health insurance through their jobs. Their plan would provide “continuous coverage” protection, so that people who remain enrolled in insurance can’t be financially penalized for getting sick; offer new federal funding for high-risk pools; and allow Medicaid participants to receive the tax credits and enroll in individual-market plans. A paramount goal of this proposal is to ensure that no one who is or becomes gravely ill goes without adequate medical care.
The plan has not been scored by the Congressional Budget Office, but according to the Center for Health and Economy, a health-care research organization, relative to Obamacare the senators’ proposal would lower premiums, result in roughly the same number of individuals covered by insurance policies and yield a significant 10-year net budget savings.
Repealing Obamacare and replacing it along these lines may result in more people dying — or fewer. That’s a pretty tough forecast to make. But as with speed limits, gun laws, agency regulations and many other policies, including Obamacare, the shape of future health-care policy will require trade-offs. There are only so many resources, so choices between directing them to health care and allowing them to flow to other uses are inevitable. (Thankfully, such choices are both reversible and adjustable.)
If Obamacare perishes — and I hope it does — conservatives should be ready to coalesce around a concrete replacement plan, like I’ve described here. And liberals should be ready to debate them, knowing all the while that they, too, are advocating policies that will fail to save some of the sick and injured from the fate that ultimately awaits us all.
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