By Ben Bartlett

Illustration by Seth Hahne

Politicians prefer to compete based on narrative. Because people tend to respond more strongly to story-lines than hard numbers, they make it a priority to tell their side of the story as loud and often as possible. When a politician’s constituency trusts their story, that politician is safe. When the politician seems to have lost the plot, he loses their trust. He becomes less predictable, and less likely to do what the constituency wants.

The problem with stories is that they are not very good at accurately conveying complicated issues. Describing, evaluating, and improving complex policy initiatives can’t be done through sound bites or brief appeals to the invisible hand of the market. Instead, they take years of expertise, a patient willingness to understand systems in their wholeness, and openness to being changed by the facts as they emerge.

Is it any surprise that we tend to have more interest in the story-line than the complex details? For some enduring reason, we love to have major initiatives explained to us in thirty seconds or less.

The recent most recent political conflict tying the spending bill and the debt limit to the funding of the Affordable Care Act (ACA) are not mere budgetary disputes. Instead, they represent a fierce and emotional separation of vision and of story-line. One side thinks the ACA reduces the luxuries of the rich and the profits of selfish corporations in order to protect the poor and the weak while broadening the national risk pool. The other side thinks Obamacare steals essential freedoms, costs too much, and forces the middle class to pay extra for everyone else’s insurance. The facts are, as usual, a little more complicated.

 

The Problem at Hand

The first great problem in American healthcare is the problem of rising costs. By any measure, even when factoring in our extreme wealth, American health care is excessively expensive. So long as the underlying causes of healthcare expense are present, trying to fix the healthcare system is like squeezing a water balloon or reshaping a ball of clay; improvements in one area often simply bubble out in the form of adverse effects somewhere else. Read more about the major underlying causes of high healthcare costs here.

The second great problem in American healthcare is related to access. There are currently two major groups for whom getting insurance coverage is extremely difficult. The first is the “working poor,” or people who are above the poverty line but for whom buying insurance is cost-prohibitive. The second is those who cannot gain reasonably-priced insurance because they have pre-existing conditions. After all, what profit-seeking company would want to pay medical bills in the thousands or even millions when the only reward is a few hundred dollars a month in premiums? Providing insurance to these groups in a way that isn’t financially destructive is quite difficult.

The third great problem is current economic conditions that encourage higher-risk people to obtain insurance, but do not sufficiently encourage low-risk people to enter the pool. As a result, health insurance companies have difficulty supporting their members because the costs of the sick outweigh the profit that comes from the premiums of the healthy.

The fourth great problem, which flows from two and three, is the problem of uncompensated care. Studies show that hospitals provide upwards of $116 billion dollars of care to the uninsured every year, and that something less than two-thirds of that is paid for. This “uncompensated care” is a nasty write-off for providers, who make up for it through cost-shifting. In other words, they have to raise their prices on everything else, which is paid for by those who are insured in the form of higher premiums.

 

What The Affordable Care Act (Probably) Gets Right

On the issue of access for those with preexisting conditions, the act states that healthcare companies cannot deny coverage on the basis of those conditions. This can only raise costs, but the ACA attempts to compensate elsewhere.

Access for the working poor is more complex. To provide them with coverage, the ACA a) encourages the expansion of Medicaid to cover people at up to 138% of the poverty level, b) provides subsidies for purchasing insurance for those at up to 400% of the poverty level, assuming they can’t get it through their employer, and c) creates “health exchanges” which are intended to simplify the discovery and purchase of health plans. This is also supposed to encourage competition between insurers, thereby driving down prices.

To prevent a possible glut of high-risk applicants (which can only be exacerbated by removing preexisting conditions as a factor in coverage), the ACA establishes the individual mandate. This regulation establishes a penalty (No, sorry, the Supreme Court defines it as a tax) for those who do not have insurance. Though this money can help support the uncompensated care problem, its real purpose is to encourage the uninsured to purchase insurance and improve the risk pool.

In other words, the ACA in its conception and design is attempting to provide greater coverage for the poor, protect those with preexisting conditions, and encourage wider participation in risk pools so that costs can be covered more easily. It also includes provisions to increase use of preventative medicine, which everyone can agree is an important goal. These are all good intentions, and it is easy to see why many Christians support them.

 

What Opponents of the Affordable Care Act (Probably) Get Wrong

The major Republican argument in opposition to Obamacare is the issue of freedom. On the basis of the commerce act, Republicans argue that a penalty for non-participation in a market is unconstitutional, akin to being forced to pay money to the city of New York for not buying a Yankees hat.

The Supreme Court agreed in a limited sense with this reasoning, but then pulled a bit of a switcheroo. They said that instead, the government can tax people for the provision of a service. In simple terms, the government provides you with a safety net by requiring that hospitals provide you with healthcare regardless of your ability to pay. Because of the high costs of medical care, it is not feasible simply to require those without insurance to self-insure. Too many times they cannot. Indeed, medical bills are already the leading cause of bankruptcy filings in the United States. The tax is there to help cover the provision of a service: guaranteed emergency medical care.

Other conservatives, committed to free market principles, have argued for the radical reshaping of healthcare based on principles of competition and the removal of the government as the major force in the market. However, changes of that magnitude are likely unfeasible at this point, and the adverse effects of such a change would fall most heavily on the most vulnerable.

 

What The Affordable Care Act (Probably) Gets Wrong

The ACA has three major areas of concern, and Democrats (who held both houses and the executive office when the ACA was passed) are very much on the hook for all three.

First, the ACA does almost nothing to address the underlying costs of healthcare. Aside from addressing uncompensated care (which in many ways is just an extension of the cost problem in the first place), the bill has more to do with redistribution of responsibility and less to do with correction of the fundamental problem.

Second, the crafters of the ACA did a very poor job thinking through its incentive structure. Early reactions suggest that business leaders, reacting rationally, may be doing exactly the opposite of what the Democrats were hoping for. Rather than compete with each other on price, insurance companies find it better to actually raise prices to protect themselves, and thanks to the transparency of the health exchange, they can compare themselves against competitors and figure out how much of a price raise the market can tolerate. A greater willingness to listen to insurance leaders would have gone a long way in setting up reasonable incentives for businesses to lower prices.

Third, the Democrats included provisions in the ACA that are morally unacceptable to many, most notably requiring coverage for most contraceptive methods. Religious groups and their sects or denominations differ on the ethics of many health programs, but the absolute requirement for health plans to fund things that many (the Catholic Church, for example) disagree with was a major act of arrogance and self-righteousness on the part of the bill’s promoters. It is true that Democrats were voted into power by the people, but they know well the difference between allowing something you disagree with and being asked to pay for something you disagree with.

 

What Opponents of the Affordable Care Act (Probably) Get Right

The greatest long-term danger in government right now, especially in entitlement spending, is cost. The programs were designed around the concept that the country’s economic engine can afford to support some compassion-based, non-revenue producing programs. However, as these programs have grown in size, complexity, and scope they have become more and more difficult to support.

Conservatives, on the whole, have been more forceful in sounding the alarm on these programs and articulating possible solutions. For example, here are some ideas that have been put forth in the category of health care that could be extremely helpful.

 

Seeking A Little More Complexity

Policy-making involves a careful balance of ethical priorities and pragmatic realities, and there are rarely black and white answers. The right way to deal with complex issues, though, is not by reducing them down to simplistic narratives.

Stories are great for a lot of things. They help us grow, they provide us with pleasure, they challenge our thinking, and they encourage us to sympathize. But they are not a wise tool for communicating detail.

We ought to call for and vote for leaders who embrace complexity, learn from experts, and accurately address root cause issues. We ought to employ our morality not as weapons in the war between us versus them, but as a set of ethical principles which help us to work through the thousands of decisions involved in crafting difficult legislation and regulations. We need to have the guts to meet complex issues as they are, and not as the cheap narrative some politician pining for votes is feeding us.