Republicans’ Proposed “Continuous Coverage” Protections Are Even More Coercive Than Obamacare’s…
Repealing the Affordable Care Act is at the top of Republicans’ agenda, though a consensus on what they will replace it with has yet to emerge. One part they’re eager to get rid of is the individual mandate, which they despise because it coerces individuals to buy health insurance.
The Republicans are right that the individual mandate is coercive. But they’re wrong that it is, in principle, immoral or otherwise undesirable because it’s coercive. Coercion can be justified if it achieves other things we value, like providing access to health insurance to as many people as possible.
That is exactly the justification for the individual mandate. The fundamental goal of the Affordable Care Act is to provide as many people as possible access to affordable health coverage. One obstacle to achieving this goal was that insurers were denying coverage or charging astronomical premiums to individuals with pre-existing health conditions. The obvious fix was to prohibit insurers from doing that.
But such a prohibition can work only if the insured pool is predominantly healthy. Healthy people, whose care costs will be relatively low, are needed to offset the unhealthy people’s relatively higher healthcare costs by spreading the risk across a larger, healthier pool. And since healthy people are less likely to buy insurance on their own accord — and will act as “free riders” and buy coverage only once they get sick — something is needed to compel them to participate in the marketplace up front. That’s what the individual mandate does — it obliges all individuals (with some exceptions) to obtain health insurance or face a (perhaps too modest) tax penalty. Since some people can’t afford coverage, low-income individuals not eligible for Medicaid are given income-based tax credits (intended to limit premiums to a percentage of their income) to help with the costs of coverage.
This is all intended to ensure that both healthy and unhealthy people participate in the individual health insurance market, so that everyone, regardless of health status, has access to affordable coverage. Republicans accept the goal, but they reject the means to achieve it. They like affordable health care for sick people, but they don’t like government coercion.
An alternative to the coercive measures in the Affordable Care Act floated by conservatives, including Paul Ryan in his “Better Way” proposal, is the “continuous coverage” protection. These protections would prohibit insurers from refusing to cover people with preexisting conditions, or charging them higher rates, so long as the individuals maintain continuous health coverage, defined in one proposal as being “continuously insured with at least catastrophic coverage for a period of at least 18 months, without a significant break in coverage.” Those who don’t are subject to coverage denials or costs as high as insurers see fit. An initial open-enrollment period will offer everyone — heathy and unhealthy — an opportunity to obtain insurance under the same plans, but those who don’t enroll during this period will not enjoy the protections.
Proponents of this solution claim that rather than compelling individuals to buy health insurance, it incentivizes them to buy it and keep it. They claim it achieves the goal without restricting liberty. “Our strong belief in individual liberty extends to health care,” Paul Ryan’s proposal says, “which is why we recognize and incentivize good behavior instead of coercing patients into government-mandated decisions.”
But is the “continuous coverage” alternative not also coercive? If we accept as sincere the Republicans’ claim that they share the individual mandate’s goal, and we acknowledge the logic behind spreading the risk in the insured pool, then we can infer that the success of the “continuous coverage” proposal requires enough healthy enrollees in the individual market. The Republicans, then, need a large number of individuals to exercise their liberty in a way that aligns with their policy goals.
They say they’re merely incentivizing good behavior, but promising to withdraw protections already enjoyed under the Affordable Care Act is an incentive only in the broadest sense of the term. Used this broadly, incentive means simply to create a set of expectations about the outcome of a particular action so as to induce someone to perform (or not perform) the action. But this broad use of the term includes coercion, which is to threaten an undesirable outcome so as to induce someone to perform (or not perform) a particular action. The “continuous coverage” proposal threatens to remove the protections for sick people if they don’t buy health insurance — during the one-time open-enrollment period — and keep it. Republicans can call their proposal incentivizing, but the more precise descriptor is coercive.
Individual mandate opponents could retort that even though the “continuous coverage” proposal is coercive in some way, it’s still better than the individual mandate because the actual instrument of coercion comes not from the government but the insurance companies — in the form of the fair coverage price, based on individual risk level. And since the government’s hand is absent, the argument would go, individual freedom is left intact, regardless of what insurance companies do. There are two issues with this response.
First, it obscures the initial conditions in which the “continuous coverage” protections would operate. The baseline created by the Affordable Care Act is that insurance companies are prohibited from denying coverage to sick individuals or charging them more. The Republicans are threatening to make people who don’t use their freedom correctly worse off than the baseline by authorizing insurance companies to do with them whatever they want. It’s not less coercive just because the undesirable outcome isn’t dispensed directly by the Leviathan. The stick will belong to insurance companies, but the government will have given it to them and sanctioned its use.
Second, proponents of the “continuous coverage” proposal need to consider the actual value of individual freedom from government intervention. It is not absolute; it’s only as valuable as the alternatives people would have in the absence of that intervention. In the case of repealing the mandate, the freedom will be mostly symbolic. It will make citizens freer in a narrow sense by thwarting the government’s ability to make them buy health insurance, but what good is that freedom if they still can’t forgo insurance without facing financially-devastating consequences?
And what good is that freedom for lower-income Americans who can’t afford coverage without assistance? If Republicans don’t provide adequate premium subsidies (and it doesn’t appear they will), then the only freedom many lower-income Americans will enjoy is the freedom to do what they have no choice but to do — endure a precarious existence without health coverage. They’ll still be unable to avail themselves of the supposed free choices in the market. And if individuals or families on the margin find themselves unable to maintain continuous coverage — perhaps because they choose to buy food or pay for housing — then they will not only be unable to keep their health insurance at the protected rates; they will be unable to re-acquire coverage because they certainly won’t be able to pay the higher ones. This is the price of revering such a narrow conception of freedom.
Let’s consider a more comprehensive conception. The political philosopher Gerald McCallum argued in a famous 1967 article that freedom is a triadic relation. It is always “freedom from some constraint or restriction on, interference with, or barrier to doing, not doing, becoming, or not becoming something.” It is “thus always of something (an agent or agents), from something, to do, not do, become, or not become something.”
According to this conception, the test for freedom isn’t whether the government makes someone buy health insurance (or prevents them from buying it); it’s whether anything does. So, Republicans are correct that with the individual mandate in effect, citizens are not free from government interference in the form of tax penalties not to forgo health coverage. But unhealthy citizens are freer, because of the mandate’s effect on the insured pool, to obtain affordable coverage; and low-income citizens are freer, because of generous tax credits, to obtain coverage.
Repealing the mandate would make citizens free from government interference to forgo health coverage. But they would not be free from the potential rate hikes or denial of coverage (both significant economic barriers) to forgo it; and if they lose the continuous coverage protections, their freedom to obtain health insurance will only diminish. Absent sufficient financial support, low-income Americans will not be free from the financial barriers to obtaining and maintaining continuous health coverage. And once the financial barriers prevent them from obtaining and/or maintaining health coverage, they will only grow, making them even less free to obtain a good that Republicans declare they want them to have.
So, the “continuous coverage” protections won’t make citizens free to go without health coverage, and they certainly won’t enhance the freedom of struggling Americans to buy it. They will just shift the barrier to freedom to a nongovernmental source that will deliver a much harsher blow to those who deviate from policy goals. They will tie the government’s gloved fist but hand the insurance companies brass knuckles — then they’ll nod permissively as the insurers beat Americans until they can’t get up.
Before Republicans profess their love of freedom and propose policies proclaiming to protect it, they should recognize that it consists of more than the size and presence of government. A kidnapped person is no freer than someone imprisoned by the state. And a sick person facing insurmountable medical costs is no freer (in fact, is less free) than someone paying extra taxes for not complying with the individual mandate.
Some restrictions on freedom, like the Affordable Care Act’s individual mandate, are justified because the value of the freedom is outweighed by other things we care about and the restrictions aren’t excessive. Other restrictions, even if they don’t arise from direct government intervention, like the devastation threatened by the “continuous coverage” proposals, aren’t justified because the cost is much too high. And both Republicans and Democrats agree that restricting insurance companies’ freedom to distinguish between healthy and unhealthy people in the individual market is — even if only temporarily — justified.
Similarly, some freedom-enhancing measures are not only justified but morally required. Not all, of course. We wouldn’t expect the government, or anyone else, to remove the financial barriers to our acquiring a mansion or taking a lavish vacation around the world. But for a basic good like health — which is necessary for, and reflective of, a decent industrialized society — calls for the government to provide sufficient assistance to those who can’t afford care are warranted. And the government is obliged to answer the call. It is obliged to enhance the freedom of those who cannot obtain health coverage on their own.
If the Republicans want to make freedom the centerpiece of their Affordable Care Act replacement, they should embrace the totality of the concept. And they should recognize that it must be balanced against other ideals if their replacement is going to achieve their own professed goals — to provide access to affordable healthcare to all.