Dishonesty, Ignorance, or What?

We hardly regard politics—certainly not the words of politicians—as a realm where truth and honesty are closely protected. Public ignorance undoubtedly often pairs with politicians' disregard for accuracy to allow lies to pass. It is still galling, though, when political process and public reflection are stubbornly resistant to the obvious. It is more disturbing yet if the ignorance seems almost willing—a deeper kind of dishonesty in and with ourselves.

By nature I am neither cynic, nor pessimist, nor one who disdains politics and public life because they can be infused with ignorance. In the last twenty-four months, moreover, I have been encouraged by the distance insurance reform has traveled, notwithstanding current efforts to repeal the most ideologically moderate of reform approaches. Nonetheless, I now find myself haunted by suspicions of a deep dishonesty in our culture. My original point of suspicion is the laudable requirement to admit patients to emergency rooms regardless of their ability to pay, but I can now add two related ones: the "insurance effect" fueling health care costs, and the mantra that prevention lowers costs (in particular, that reducing smoking will lower costs).

Since enactment in 1985, the Emergency Medical Treatment and Active Labor Act has required hospitals to admit patients for emergency care regardless of ability to pay.¹ It now provides a historical and legal anchor for a fairness and efficiency argument to mandate insurance to achieve universal access. The argument begins with the fact, achieved by EMTALA, that the United States already has universal access to emergency care. Exemplifying the underlying moral principle of rescue, this law has wide, deep support: first passed with bipartisan support in 1985, reaffirmed in 1998, and not politically challenged in all the tumultuous debates of 2009-2010.

If we agree that universal access to emergency care is a good thing, as we apparently do, then unfairness, free-riding, and inefficiency drive the argument to a mandate. Most of the cost of providing emergency care to those who cannot pay is shifted to people with insurance, who consequently pay higher premiums. These payers are not necessarily the parties from whom it is fair to extract the "tax" to fund this access. Moreover, the cost shift enables some to free-ride unfairly by escaping paying for insurance, knowing that emergency care will be available anyhow. In any case, emergency care often ends up substituting for primary and other care that is not accessible—a very inefficient substitution. In a context where universal access to emergency care is guaranteed but other basic care is not, the only feasible remedy for this unfairness and inefficiency is to mandate insurance for basic care more generally.²

An oddity thus created for our current situation deserves notice: a key link in the argument for an insurance mandate, now being challenged as unconstitutional, is itself a federal law that's not been challenged. Also, notice how sly or shrewd a step EMTALA may have been, in historical hindsight, for the cause of universal access: put in place access to emergency care, then let the momentum and pressure from it roll all the way to a broader access. Pull that off, moreover, without complicating the political prospects of the initial step by owning up to how to pay for access to ERs.

In retrospect it is not hard to understand why a society resistant to universal access (and to paying for it) might choose emergency care as one of its first major steps toward universal access. Not all that respectable, perhaps, but understandable: live up to the moral call of rescue by guaranteeing emergency care, but then dodge financial responsibility.³ Here the mandate is easy to leave unfunded since an avenue of "backdoor" financing is available. Emergency care is provided by institutions (hospitals) that are large enough to absorb the immediate costs and shift them onto other payers. No such hidden financing is feasible for primary care, which is usually delivered in smaller institutional settings. With its financing thus "cheap" and politically enticing, it is hardly any wonder that access to emergency care became an irresistible early step in insuring the population...