JAMA Forum: Obamacare’s failure to fulfill its moral ambition

A health policy goal among some on the left is universal coverage. On the right, the emphasis is often affordable coverage, even if it’s only for some (like those with continuous coverage). The center, in my view, is universal access to affordable coverage. And that just happens to be the best characterization of the main ambition of Obamacare.

Can we justify this ambition with more than its claim to the political center? I think we can. In a new post on the JAMA Forum I articulate a moral argument for universal access to affordable health insurance, borrowing from the work of Daniels, Saloner, and Gelpi and Saloner and Daniels. The starting point is an assertion that we have a moral obligation to protect opportunity, access to health care being one necessary condition for it.

Access to health care is enhanced by health insurance. As Daniels, Saloner, and Gelpi argue, universal health insurance is a means to this end. But it’s not the only way. The key is to recognize that equality of access is not equality of receipt. The authors are not suggesting that we have a moral obligation to ensure that everyone receive the same amount of health care, merely that everyone have the same degree of access to it.

This more modest obligation would be met in a system that does not cover everyone but extends equal opportunity of access to affordable coverage to everyone. That is, equal opportunity to obtain coverage is a necessary condition for equal access to health care, though some may choose not to avail themselves of that care or that coverage. Put another way, if we are morally satisfied with a regime under which people can choose whether to receive care, we ought to be morally satisfied with one under which people can choose whether to obtain coverage for it, so long as there is equal opportunity of access to that coverage and the care it facilitates.

So much for a moral justification of the law’s ambition, what about its actual implementation? Here it fails; universal access to affordable coverage has not been obtained and is not expected to be under the law. Millions of poor residents in states not expanding Medicaid lack it. And, as Jed Graham of Investor’s Business Daily recently reported, some families covered by exchange plans could face out-of-pocket costs as high as 40%. One can hardly call that affordable.

Obamacare’s ambition may have a reasonable, moral foundation, but it has not fulfilled it. I wrap up the post with some suggestions on how to better align policy with what morality demands of it. Go read the whole thing.


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