Such is my luck that a few weeks after the Obamacare rollout I found myself shopping for insurance on the infamous government exchange. In October, my employer announced a significant reduction in its health care benefits, and I wanted to find out if my wife, who was insured under my plan, could get better coverage through healthcare.gov. True, as a well-informed political observer and columnist for The Cresset, I knew the government website was unworkable, but necessity left me no choice. I ventured onto healthcare.gov, where I managed successfully to fill in my wife’s personal information and ascertain her eligibility, only to discover that I could shop on the exchange for different health care plans without a problem. And this wasn’t in November after the “tech surge” had averted near total disaster, but in October, at the height of the rollout debacle. It wasn’t as easy as shopping on Amazon, which surely did raise my anxiety level, and, in all honesty, when I returned to the website a few days later it wasn’t working at all. But then I struck upon the idea of calling the health insurance companies directly, and I discovered these companies had agents who had heard about the Affordable Care Act and who knew how to help me. Slowly it dawned on me that anyone with a modicum of wherewithal could purchase insurance on the exchange.

But what, I wondered, explained the difference between my personal experience and the reports in the news? Might there be, I wondered, groups with an interest in seeing Obamacare fail that were exaggerating its difficulties? Could it be that the news industry, seeking to boost television ratings, was overdramatizing the story? Would political pundits, who earn their living by finding something to say, ever blow things out of proportion? Perhaps a conglomeration of interests was generating play-by-play tactical commentary on the vicissitudes of Obamacare that made it difficult to get a clear picture of what was actually going on. I needed a reality check. I wanted to think concretely about the state of American health care and the alternative proposals for improving it. I even did some research. 

According to a survey of eleven industrialized nations conducted by the Commonwealth Fund, 37 percent of adults in America went without recommended care in 2013, or failed to see a doctor when they were sick, or chose not to have prescriptions filled because of prohibitive costs. Twenty-three percent of adults reported that either they could not pay or had serious problems paying their medical bills, compared with 13 percent in the next highest country on the survey. Health care in America, despite resting on free-market principles, is significantly more expensive, both as a share of GDP and in terms of per capita spending, than in any other industrial nation. According to 2013 OECD data, the US spends $8,500 per person on health care, $3,000 more than the per capita spending level in the next highest country, and more than twice the median spending of twenty-one industrial countries. The US health care system is also significantly more bureaucratic than that of other countries. The United States spends $606 per capita on administrative costs related to health care, more than twice the next highest country, France, and vastly more than the administrative costs ($55 per capita) in that American bugabear, so-called socialist Sweden (Commonwealth Fund). To top it all off, more than forty million Americans are denied access to health care, because they do not (or did not prior to the Affordable Care Act) have insurance. Lack of access may explain why the United States falls behind most other industrial countries in basic measurements of health such as life expectancy and infant mortality rate. Indeed, the American health care system is so abysmally inefficient and inequitable that 75 percent of Americans surveyed by the Commonwealth Fund stated they thought the system was in need of basic reform.

Ugly facts like these convinced me that the status quo ante Obamacare was unacceptable. Health care reform was long overdue. That doesn’t mean that Obamacare gets a free pass on criticism, but it does mean criticisms need to be contextualized. What are the alternative proposals for reform? Do critics of the Affordable Care Act propose something better, or are they seeking to restore the status quo ante? Insofar as I can discern, existing alternative Republican proposals to Obamacare are piecemeal approaches that trade away the goal of universal coverage.

After all, the identified strategies for getting to universal coverage are relatively few. One way to get there is through socialized medicine, but no one proposes anything as radical as that. Some on the American Left would like to see a single-payer health insurance system. They argue that if the entire population paid into the same health insurance fund this would distribute risk more effectively than do multiple insurance companies and also reduce administrative costs. However, a single-payer system would dismantle the private insurance market and increase the government’s role in health care in ways that depart from current practice quite dramatically. A more conservative approach is to push the private insurance system toward universal coverage by creating a market exchange in which everyone is required to participate, generating both competition and choice in ways that may also reduce costs over time. The idea of a mandate requiring all individuals to purchase health insurance was once considered a conservative idea and was promoted by the Heritage Foundation in the 1980s. This strategy was used by Mitt Romney in Massachusetts, but today it is associated with Obamacare and unpalatable to Republicans. Perhaps a new generation of Republican leaders has developed a different and better strategy for arriving at universal coverage, which for unknown reasons they are keeping a secret. Or perhaps they have abandoned the goal of universal coverage altogether.

That the latter might be the case is suggested by the kinds of criticisms Republicans make of Obamacare, which often begin by invoking something akin to the Ayn Rand apocalypse. We need to take a good hard look at reality, they say; taxes and spending are out of control, and if we don’t rein them in soon we face a Doomsday scenario. According to this argument, Obamacare is simply economically unfeasible. But if Obamacare is unfeasible, the same must be true of universal coverage, yet somehow almost every other industrial nation has managed to achieve it.

Moreover, the realities about government spending are not as Republicans describe. In 2013, total federal spending amounted to 22.7 percent of GDP, which is in line with the forty-year historical average. Nor, by international standards, are Americans overtaxed. Total US tax revenues (including federal, state, and local taxes) in 2013 averaged a little over 30 percent of GDP, well below the median 44 percent of GDP for industrial countries. Furthermore, in 2013 the fiscal deficit dropped to $680 billion, a 51 percent reduction from 2009. The reality is that American government is one of the smallest in the industrial world. It is quite arguable that the size of the US government is less of a drag on the US economy than suppressed aggregate demand, caused in part by stagnant wages, which are caused in part by the increasing percentage of their income Americans devote to health care.

Never much flummoxed by facts, the prophets of Randian realism eventually invoke principle: Obamacare means the end of liberty. You see, it requires everyone to have health insurance. Universal coverage, it turns out, is an evil we should eschew rather than a goal we should attain. The “liberty dilemma” arises from the fact that universal access is economically feasible only when both the healthy and sick participate in the system. If people are free to opt out of health care when they don’t need it and then opt back in when they do, the system collapses. But unless people are free in precisely this way, the argument goes, we will live under tyranny. The cost of achieving universal coverage is simply too great; it means abandoning the American way of life.

One never knows for sure if this is a slippery-slope argument (any fool can see that universal coverage opens the gates to collectivization of private property and a dictatorship of the proletariat) or an argument from libertarian principle. Government has the authority to conscript young people and send them to their death in war, it requires parents to educate their children, and it levies taxes on the willing and unwilling alike. These instances would seem analogous to the ordered exercise of freedom needed to achieve universal health care coverage. One thus suspects that the “liberty dilemma” rests upon a Randian libertarianism that is antithetical not only to the idea of a common good, but even to the idea of government itself.

The truth is that America’s failure to provide universal access to health care has been a long standing moral affront. Obamacare attempts to redress that failure, whatever its flaws. Its flaws are certainly a legitimate object of criticism, but critics who reject Obamacare completely need to state clearly what they would put in its place. They should also come clean on the question of universal coverage.

H. David Baer is Associate Professor of Theology and Philosophy at Texas Lutheran University.

Works Cited

Commonwealth Fund, The. “New 11-Country Health Care Survey: U.S. Adults Spend Most; Forgo Care Due to Costs, Struggle to Pay Medical Bills, and Contend with Insurance Complexity at Highest Rates.” http://www.commonwealthfund.org/News/News-Releases/2013/Nov/New-11-Country-Health-Care-Survey.aspx (Press Release: November 13, 2013).

Organization for Economic Co-operation and Development. “OECD Health Data 2013 - Frequently Requested Data.” www.oecd.org/health/health-systems/oecdhealthdata2013-frequentlyrequesteddata.htm.