ObamaCare under the Trump Administration: Health Care or Health Insurance (Cristina Richie)

Catholic Social Ethics

When the Patient Protection and Affordable Care Act, also known as ObamaCare, was passed in 2010, it was hailed as a long over-due step toward extending health care insurance to millions who were uninsured, and a move toward justice and equity in health care access.

To be sure, it was also fraught with fierce opposition from certain organizations who opposed the coverage of certain essential health benefits, including contraceptive preventative care. The United States Conference of Catholic Bishops’ (USCCB) 2010 Letter to Congress voiced disapproval of a bill that did not meet their moral criteria on life and conscience. Lawsuits escalated and the concern that the individual mandate to maintain “minimum essential coverage” was unfair, burdensome, or even unconstitutional was eventually brought to the Supreme Court in 2012.

But the fundamental ethical claims regarding the law remain. One Political Theology Today blogger wrote in reflection: “Ensuring that all Americans pay into the pool (whether in the form of premiums or the tax penalty), creates a more just society for all.” Now, however, the country faces the upending of this controversial law.

The Trump campaign promised a full repeal of ObamaCare, including the contested individual mandate. As his plan develops, Trump assures Americans that we will have universal access to health insurance, instead of universal coverage. These terms are ambiguous, and the nuances may be lost on both those who are eager to avoid penalties imposed by the Individual Shared Responsibility fee (i.e., the individual mandate) and those fearful of losing health insurance coverage. Universal access means that people will be provided with the means by which they can obtain some health insurance, whereas universal coverage means all people will have health insurance. But should universal access, or even universal coverage, be the goal of society? Or, rather, are we interested in universal health care?

Pope John XXIII clearly states in Pacem in Terris that human beings have the right to “the means necessary for the proper development of life, particularly food, clothing, shelter, medical care, rest, and, finally, the necessary social services” (no. 11). Christians articulate this—and other—human rights based on an understanding of the intrinsic value and dignity of the person. Moreover, human rights have resonance with the values of a secular society.

The 1948 Universal Declaration of Human Rights is often cited as a reason and rationale for providing health care as a right. Physician Paul Farmer has made “health care as a human right” his mantra. The readily familiar language of human rights therefore allows a large number of people to assent to and implement health care as a human right.

The United States Conference of Catholic Bishops affirm that “the basic right to life implies, and is linked to, other human rights… that every person needs to live and thrive—including food, shelter, health care, education, and meaningful work.” This is indisputable. However, health care cannot be conflated with health insurance.

First, health insurance often goes above that which can be considered a medical need. Health insurance companies determine what, if any, services they will provide for insurance purchasers. The outcomes include arbitrary standards for who can access treatments and how often, but more than this, it results in unnecessary treatments and over-use of non-medical services.

Many times doctor visits and medical procedures are unrelated to preventing or treating physical diseases. Current health insurance policies provide medically unnecessary procedures like Botox, breast pumps, and artificial insemination. Coverage of these luxury goods do not eliminate health care disparities. Lobbying for health insurance over health care exacerbates the divide between the rich and poor, making a veritable medical market divided by insurance brands. This is a matter of justice, both at the individual and corporate level.

Second, while the government is set up to facilitate order, freedom, and rights, government-enforced health insurance does not guarantee access to, or the use of, health care services. A sizeable number of citizens are unable to access health care because of its cost, even after ObamaCare. Even the insured face high co-pays and deductibles that prevent them accessing recommended prescriptions or procedures following a doctor’s visit. In other cases, those with health insurance avoided medical care because of the fear of receiving a staggering bill.

Even after the implementation of the Affordable Care Act in the United States, approximately 41 million Americans were still uninsured as of 2015. Many are too old to qualify for their parents’ plans, or do not have jobs where their employer offers health insurance, or have to pay an enormous amount from their paycheck for, effectively, a service they will not use. Financially unstable young people are faced with paying fines for being unable to secure insurance, requiring them to make choices about accessing needed health care or purchasing superfluous health insurance. And this only speaks to the financial barriers that prevent people from using health insurance. Other factors that prohibit people with health insurance from accessing health care may include fear of harassment, discrimination, prejudice, or remote location. If health care is a human right, it should not be so financially prohibitive that even those with insurance are afraid to access it. Nor should it be so exclusive that only white, straight, urban men are taken care of once inside the walls of health care facilities.

Third, health insurance is not only way to secure health care, even in this modern era. There is more than one way to pay for medical services—through health insurance, out of pocket, or even bartering for health care, as many people have done for centuries and as many continue to do today. Catholic social teaching argues, “One of the principal duties of any government…is the suitable and adequate superintendence and co-ordination of men’s respective rights in society” (no. 62). Homogenization of rights is antithetical to liberty.

Yet in 2010 Justice Ruth Bader Ginsburg opined, “In requiring individuals to obtain insurance, Congress is therefore not mandating the purchase of a discrete, unwanted product. Rather, Congress is merely defining the terms on which individuals pay for an interstate good they consume” (p. 22). That is, the law defines the means by which all citizens have the option to access basic health care (while at the same time leaving the health marketplace unregulated for luxury purchases not covered by health insurance). This government imposition does not  secure the Catholic aim of adequate and affordable health care for all because it operates at the level of means to achieving the good, without actually guaranteeing that good.

To be sure, the government cannot force people to go to a hospital or primary care doctor. Even mandatory vaccines and inoculations have exceptions. But we can decrease health care costs by authentic health care reform that addresses health care insurance as a business predicated on profit.

Benedict XVI contended in Caritas in Veritate that financial gain cannot be the exclusive goal of industry; it must have the common good as its ultimate end (no. 21). The American health care system is currently predicated on costly health insurance that covers luxury medical goods, favors the already privileged, and creates a monopoly in payment for health care.

Whether Democrat or Republican, ill or healthy, young or old, insured or not, affordable health care—not insurance—is one principle of Catholic social teaching that demands more attention, and must stay at the forefront of the debates about health insurance access, coverage, and reform. Health care is a human right; health insurance is not. The question is: will the Trump Administration see it that way?

Cristina Richie is an Adjunct Assistant Professor of Health Care Ethics at Massachusetts College of Pharmacy and Health Sciences in Boston, MA. and has also taught Bioethics at Tufts University and Medical Ethics at Zaporozhye Bible College and Seminary (Ukraine). She has written over thirty articles, book reviews, and book chapters on various ethical topics inclusive of assisted reproductive technologies, global health care justice, war and combat, and environmental sustainability. Her PhD is from Boston College and she also has clinical ethics consultation training from the University of California, Los Angeles Health Ethics Center.

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